Evaluation & Management Reporting
NOTE: only comprehensive level requires OS only.
NOTE: the coder uses the exam findings to report the services NOTE: 1 Constitutional + 7 OSs = 8 => comprehensive exam NOTE: 1995 DG - The medical record should be complete and legible. |
History (subjective information)
E/M Key Components
Four Elements of History
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History of Present Illness HPI
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History Levels
Problem Focused: focused on CC, brief present problem, No PFSH Expanded Problem Focused: focused on CC, brief present problem, problem-pertinent review of systems. no PFSH. Detailed: focused on CC, extended history of the present problem, extended ROS, pertinent PFSH directly related to the patient's problem. Comprehensive: most complex, CC, extended PHI, complete ROS + PFSH. |
Within the Levels
Problem Pertinent: Is a review that is focused on that organ system (OS) involved in the chief complaint, such a s a fractured finger in which the musculoskeletal system is the center of the review Extended: includes a review of the system directly involved in the chief complaint, plus related (up to 9) other systems. Complete: ROS includes at least 10 of the 14 OSs Example: presenting problem or chief complaint is a red, swollen knee, the system review would be the musculoskeletal system |
Examination (objective information)
1. Examination Elements
2. Contributory Factors
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E/M Exception
The first three of these components (i.e., history, examination and medical decision making) are the key components in selecting the level of E/M services. An exception to this rule is the case of visits which consist predominantly of counseling or coordination of care; for these services time is the key or controlling factor to qualify for a particular level of E/M service. For certain groups of patients, the recorded information may vary slightly from that described here. Specifically, the medical records of infants, children, adolescents and pregnant women may have additional or modified information recorded in each history and examination area. |
Problem focused: examination is limited to the affected BA or OS identified by the CC. It involves 1 OS or BA
Expanded problem focused: limited examination of the affected BA or OS and other related BAs or OSs. It involves a limited examination of 2-7 BAs or OSs. |
Detailed: an extended examination of the affected BAs or related OSs. It involves an extended examination of 2-7 BAs or OSs.
Comprehensive: This is the most extensive examination; it encompasses at least 8 OSs. |
Audit Forms: