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6 Elements: Location, Timing, Associated Sign and Symptom, Duration Type of History HPI Problem Focused (99201, 99213) Brief (1-3) Expanded Focused (99202, Brief (1-3) Detailed (99203, 99214) Extended (4+) Comprehensive(99204, 99205,99215) Extended (4+) 6
7 ROS Problem Focused (99201, 99213) N/A Expanded Focused (99202, Problem Pertinent(1) Detailed (99203, 99214) Extended (2-9) Comprehensive (99204, 99205,99215) Complete (10+) 7
8 PFSH N/A (99201, 99213) N/A (99202, Pertinent (99203, 99214) (1-3) Complete (99204, 99205,99215) (3) 8
9 Type of History Problem Focused Expanded Detailed Comprehensive HPI Brief (1-3) Brief (1-3) Extended (4+) Extended (4+) ROS N/A 1 System Extended (2-9) Complete (10+) PFSH N/A N/A Pertinent (1-3) Complete (3) 9
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11 Psychiatric Constitutional-vitals General appearance Cardiovascular Respiratory GI 5 systems examined Limited exam of affected body area/organ system and other related systems Psychiatric Constitutional- 3 vitals recorded, General appearance One bullet for cardiovascular One bullet for respiratory effort One bullet for GI Five total bullets=problem focused exam 11
12 1995 Organ Systems 1995 Expanded Examination 1997 Examination Guidelines Expanded 5 systems examined Expanded Limited exam of affected body area or organ system and other related systems bullets Problem focused exam
13 MCM Section A 13
14 A B C D Problem Categories Number Points Score Self-limit or minor (stable, improved, or worsening) Max= 2 1 Established problem: stable, improved 1 Established problem: worsening New problem, no additional work-up planned 3 New problem: additional work-up planned Total: 14
15 Type of Data (Amount and Complexity) Points Review and/or order of clinical lab tests. 1 Review and/or order of test in the radiology section of CPT (nuclear medicine and all imaging except electrocardiography and cardiac cath.) Review and/or order of test in the medicine section of CPT (EEG, EKG, echocardiography, cardiac cath, non-invasive vascular studies, pulmonary function studies). Discussion of test results with performing physician. 1 Independent review of image, tracing, or specimen. 2 Decision to obtain old records and/or obtaining history from someone other than patient. Review and summarization of old records and/or obtaining history from someone other than patient. Total: Level of Risk Presenting Problem Diagnostic Procedures Ordered Management Options Selected Minimal Self-limited/minor Lab w/36415 Chest x-ray Urinalysis Low 2 or more self-limited/minor 1 stable chronic Acute uncomplicated illness or injury Non-stress tests Skin biopsies Labs w/arterial puncture Non- imaging w/contrast Rest Gargle Superficial bandages OTC drugs Minor surgery/no risk factors PT/OT IV fluids w/out additives Moderate 1 or more chronics w/mild exacerbation 2 or more stable chronics Undiagnosed new problem Acute complicated injury Stress tests Diagnostic endoscopies-no risk factors imaging w/contrast Minor surgery w/risk factors Elective major surgery Prescription drug management IV fluids w/additives High 1 or more chronics w/severe exacerbation Acute/chronic illnesses pose threat to life Abrupt neurological status imaging w/contrast & risk EP tests Diagnostic endoscopies w/risk Elective major surgery w/risk Emergency major surgery Drug therapy w/monitoring DNR 15
16 A. # of Diagnoses or Mgmt Options 1 Minimal 2 Limited 3 Multiple 4 Extensive B. Amount and/or Complexity of Data 1 Minimal or Low 2 Limited 3 Moderate 4 Extensive C. Highest Risk (Table of Risk) Type of Decision Making Minimal Low Moderate High Straight Forward Low Moderate High HISTOR Y History of Present Illness Review of Systems Problem Focused 1-3 Expanded 1-3 Detailed 4+ Comprehensive PFSH 0 0 1of 3 2 or 3 of 3 EXAM Problem Focused bullets Expanded 2-7 At least 6 bullets Detailed 2-7 At least 12 bullets Comprehensive 8+ All elements and shaded MDM Straight Forward Low Moderate High 16
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22 Review of Systems Constitutional Denies: fatigue, malaise, excessive weight change Eyes Denies: double vision, blurred vision, vision loss, floaters Cardiovascular Denies: chest pain, palpitations, irregular heart beats, syncope, dyspnea on exertion Respiratory Denies: shortness of breath, wheezing, cough Neurologic Denies: tingling, memory difficulties, seizures, tremors, loss of balance Endocrine Denies: polyuria, polydipsia, significant hypoglycemia, significant hyperglycemia 22
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Past Surgical History
Name: DOB: Check All That Apply Past Medical History o Anemia o Aneurysm o Asthma o Bipolar o Bleeding Disorder o Blood Clot o Brain Tumor o Bronchitis o Cancer o Crohn s Disease/Ulcerative Colitis o Depression