E/M Documentation Auditor's Instructions Refer to data section (table below) in order to quantiy. After referring to data, crce the entry farthest to the RIGHTin the table, whicl. est describes the HPI, ROS and PFSH. If one column contains three circles, draw a line down that column to the bottom row to identify the type of history. Ifno column contains three circles, the column containing a circle farthest to the LEFT, identifies the type of history, ‘Avior completing this table which classifies the history, cirte the type of history within the appropriate grid in Section 5. Wei? Sus ot chronic condtions: mt T 1 1 condition 2 conditions: ‘3 conditions ‘Status of | i a a 1-2 chronic: ‘oR conditions i Tl history of present lines) cements aT t Dlocaton ChSevery CE) Tming Moding factors laa Toualty [7 Duration _£ Gontext_ 5) Associate signs and symptoms ROS (review of systems) fo Se Geshe 1 Constitutional 2 Earsinose, 2) GI 1D Integumentary Endo (oss, etc) mouth, throat GU (skin, breast) El Hervlyrph None Petnento | Extended | “Compe O Eyes cardvasc Muscle © ONeuro Cl Allimmuno | poblem | 28 ayn) | D Resp Drsych 0 Allothers negative| (sytem) | PFSH (past medical, family, social history) areas: o| alo None | Pertinent |**oomgles ! insoratea)| @erane> {D easthictory (the patents past expriances wih nesses, operation, tries ad toatmeris) [Gy Fay istry (a revo of meszal evants inthe patonts amy. clung eases which mey be heredtary or lace the patent at fk). [Cy Saaaiton (an age appropiate rvaw of past and current activites) “Complete ROS: 10 or more systems, or some systems with statement “all others nogative". “Complete PFS! {; 2history areas: a) Established patients - office (outpatient) care; b) Emergency department. 3history areas: a) New patients - office (outpatient) care, domiciliary care, horn hospital care; d) Hospital observation; e) lial Nursing Facility Care are; b) Consultations; ¢) initia, NOTE:For certain categories of E/M services that include only an interval history, itis not necessary to record information about the PFSH. Please refer to procedure code descriptions. fefer to data section (table below) in order to quantify. After referring to data, identify the type of examination Circle the type of examination within the appropriate gid in Section 5, Limited to affected body area or organ system (one body area or system related to problem) | PROBLEM FOCUSED EXAM | Affected body area or organ system and other symptomatic or related organ system(s) EXPANDED PROBLEM (additional systems up to total of 7) FOCUSED EXAM Extended exam of affected area(s) and other symplomatic or related organ system(s) (additonal systems up to total of 7 or more depth than above) DETAILED EXAM | General mutisystom exam (@ or more systems) or complete exam ofa single organ aysiom | Gg (complete single exam not defined in these instructions) COMPREHENSIVE EXAM Body areast oD o ay 1 Head cucing face Chest, ncung breasts and axing C1 Absomen CONS | 4 soqy | Upto? | Upie? | Borne 1D Back. inciuding spine C1Genitaia, grin, butocks =O. Eachestremity | areacr | syttoms yams | sytame ‘Organ systems: ‘system L 1 consttstonal Ch earsrose, CO Resp Ch nuseulo C0 Payen (es. vials, gen app) mou teat I Gt OF sin Bi Hortymphem Eyes Cardovascaar C1 GU Natwo cOMPR HENSIVE PROBLEM EXPPROB FOCUSED FocuseD DETAILEDEan eee) Number of Diagnoses or Treatment Options Amount andior Complexity of Data Reviewed dntty each problem or treatment option mentioned in the record, ntar the number in each ofthe categories in Colum B inthe tabla For each category of reviewed data dented, cele the number nthe points >elow. (There are macmum number in two calegoris,) DO not calumn Tt the points. Zategoriza the problem(s) ithe encounter fs daminated by Bring toto ne An Final Resut fer Complenty (tabla Below) ‘ring toa tne in Fal Rul for Comploety (taba below) Use he sh abe below asa gui o assign rik actors. ti ueretood tha th tab elow doos ‘onl all specie instances of medial cate the lable intended io be used ae a guide, Cite Ge, post apprprinia facta) in each calansry. The overall moarure of fex te highest ve ie. 2eunselingleoordnating of care, end duration of ine is net spcifed ; sounsellngoorsnatng of cae, a vas ‘Amount andlor Complexity of Data Reviewed "Number af Disnnewes or ireais Reviewed Da Poin | eve andor or fica ee f a q | evn ance ante of ssn he racciog ancion of PT. 1 | Review andor or fei ha madi ac 1 Selsmted or mirer sis nie ma “cer ! {Sale inroved or worzeing) rere | izcusion of test suits ih promina ahaa | t| Ea proba (o BT Sab, ROT 1 Decision obtain od reords ander bain histo tom i ‘Someone one thn patent Est pablo earner werenna z © Faview and sumaieatin of od ecoas ander Sang Tiny tion (lo exarinar ne adios 3 eter fom somwane other th patent andlor scusion of bad HC Barnes ae Care tth another hes car prover 2 POA ew 1. oxo dl wou sane ‘ a SS Tae Independent vsuazation of image, tracing specimen oak ft sel review 2 Bi cy error come 8 &C and pth prductin cn. ieee nee Bed ener ai trcotrm 3 TOTAL Fa fy or Morality Err the att fk Seed rns cca Com tase an Presenting Problem(s) Diagnostic Procedure(s) Management Options s = 2 ‘Ordered : Selected + mitintat serpin ee ae cold vet tea carps * Srecee” fico Sr ooscoe acne Soucy iors. “eyeseagracraamer | «gr marca sete Moderate | *to-iire neat ee re | creme Sere aetna ooo Ce EEE moronic Energie ao sur open prcuarecus 9 hice sre cine ae reyoesatato | + Codowsevar imag Ss wi creas fot Gosyhrcion 99 le boars Soe Mt Ice ake High | eer ee mel ee | SORE rec, | |p feet {eos Sobenro teste iebiecciweas ie eeeacoor ary Sipe tes age ‘emmy olvoo rreatons, Final Result for Complexity 2a tine don ny cat nh 2 cs ter typo deo ming io ‘ateainn. Chere ray ane Sewn be ealunn win ha Sore he a ‘ar compsng teal wen Sats company the peo Sees ‘ing wine oop tain Sesons Final Result for Complexity be piso cuenta ie ard spose euncango ott ae doen (rere tn he enc, ne may Sarna estes, Socuranttn ay opie drt depos eet eure ace coptarc A | Number aapnoses or ‘weatment opens B | bighost Risk [boes oeumeiasen vel ol tme? ™:Untcnpasweare | C) Yes CJ S| routed compre ar de: mere seers ant tenergecsraboan? |] Yes] _ [oscar metta nar ariarweeemmncmoirse |) Yes EI Type of decision making = fall isWeTs are "yes" select level based on tm,