Draft "New Framework" for Evaluation and Management (E/M

Summary of June 1998 (Revised) Draft “New Framework” for Evaluation and Management (E&M) Documentation Guidelines

Attached for review and comment is the most recent draft of the revised Evaluation and Management (E&M) Documentation Guidelines. This draft simplifies and shortens guidelines for the three key components for selecting and reporting an E&M code, relative to the 1997 guidelines and corrects for a technical error made for the eye examination. Comments should be submitted to the address below by November 25, 1998.

An earlier draft was presented at the E&M Documentation Guidelines “Fly-In” meeting on April 27, 1998. It was developed in response to widespread physician concerns with the 1997 guidelines and reflected detailed comments received from the Federation and others. In May 1998, the CPT Editorial Panel made further revisions based on comments at the “Fly-in” and other sources. A revised version was available at the June 1998 meeting of the AMA House of Delegates. Following House action on this matter, the planned circulation for review was halted pending the outcome of discussions between the AMA and HCFA on application of AMA policy adopted in June.

As described in the cover letter accompanying this draft, HCFA has now determined that it will proceed with development of new E&M documentation guidelines and that the June 1998 draft will be the starting point for this effort, which will result in new HCFA documentation guidelines. HCFA has also asked the AMA and its CPT Editorial Panel to provide technical editorial input into this process. For the reasons outlined in the cover letter, the AMA has agreed. The CPT Editorial Panel will address this issue at upcoming meetings and will evaluate and act on all comments received, with the goal to have a version ready for pilot testing by Spring 1999. Relative to the 1997 guidelines, this draft:

Shortens the document substantially.

Clarifies that a code may be selected and documented based on counseling/coordination of care, without reference needed to any other dimension of code selection (i.e., history, examination, medical decision making).

Emphasizes that for established patients, only two of the three key components need be performed

(i.e., history, examination, complexity of medical decision making).

Simplifies history selection by allowing documentation of two of the three history areas (HPI, ROS,

and PFSH) instead of requiring all three to be documented.

Adds a note that, when a history can not be obtained due to the patient’s condition

(e.g., inability to communicate, urgent, emergent situation), the history is deemed “comprehensive”

for coding and documentation purposes.

Simplifies examination criteria by eliminating confusing instructions (e.g., “perform all elements”, shaded and unshaded boxes), while enhancing clinical flexibility by eliminating rigid distinctions between general multi-system versus single system examinations.

Simplifies the medical decision making component by eliminating one level of complexity (straightforward) - the proposed levels are: low, moderate, and high complexity.

Further simplifies the medical decision making component by allowing the highest complexity

element (i.e., the number of diagnoses/risk of complications, diagnostic procedures/tests and

or data to be reviewed, or management options) to drive the level of medical decision making

selection. This change eliminates the need to make a separate selection from the table of risk

and then entering that decision into another matrix.

Other clarifications include: These documentation guidelines are not applicable to the Preventive Medicine Services, Critical Care, or Neonatal Intensive Care codes; any record format for documenting history (including preprinted history forms completed by the patient and reviewed by the physician) is acceptable; the chief complaint and reason for the encounter requirements are not applicable to inpatient hospital services; definitions of chief complaint, reason for encounter, and brief/extended history of present illness have been added.

Comments, including specific recommendations and suggested revisions should be sent in writing by November 25 to Guidelines, Division of CPT Editorial and Information Services, American Medical Association, 515 N. State Street, Chicago, IL 60610; faxed to 312-464-5762; or e-mailed to [email protected].

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.Draft “New Framework” for Evaluation and Management (E/M) Documentation Guidelines

Documentation — The Basics

The following are the basic principles of documentation. They apply to all types of medical and surgical services in all settings.

1. The medical record should be complete and legible.

2. The documentation of each patient encounter should include or provide reference to:

The reason for the encounter and, as appropriate, relevant history, examination findings and prior diagnostic test results;

Assessment, clinical impression or diagnosis;

Plan for care; and

Date and legible identity of the observer.

3. If not specifically documented, the rationale for ordering diagnostic and other ancillary services should be easily inferred.

4. Past and present diagnoses should be accessible to the treating and/or consulting physician.

5. Appropriate health risk factors should be identified.

6. The patient’s progress, response to and changes in treatment, and revision of diagnosis should be documented.

7. The CPT and ICD-9-CM codes reported on the health insurance claim form or billing statement should be supported by the documentation in the medical record.

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Select the Level of E/MIn accordance with the Evaluation and Management Services Guidelines for the selection of the appropriate level of E/M Services (see page 8 of CPT), all of the key components (ie, history, examination, and medical decision making), must meet or exceed the stated requirements to qualify for a particular level of E/M service for the following new or initial patient categories/subcategories: office, new patient; hospital observation services; initial hospital care; office consultations; initial inpatient consultations; confirmatory consultations; emergency department services; comprehensive nursing facility assessments; domiciliary care, new patient; and home, new patient.

Two of the three key components (ie, history, examination, and medical decision making) must meet or exceed the stated requirements to qualify for a particular level of E/M service for the following established or follow-up patient categories/subcategories: office, established patient; subsequent hospital care; follow-up inpatient consultations; subsequent nursing facility care; domiciliary care, established patient; and home, established patient.

See page 15 of the guidelines when counseling or coordination of care dominates the encounter.

History

The extent of the history that is obtained is dependent on the physician’s clinical judgment and the nature of the presenting problem(s) or the reason for the encounter.

If the physician is unable to obtain a history from the patient or other source, the record should describe the patient’s medical condition or other circumstance which precludes obtaining a history.

This includes urgent/emergent condition(s), patient’s inability to communicate, or the patient is at a very high level of risk, where immediate action is necessary.

Documentation of the circumstances related to the inability to obtain a history will be deemed equivalent to a comprehensive history.

CPT describes four types of history:

Problem focused

Expanded problem focused

Detailed

Comprehensive

Each type of history is made up, to varying degrees, of the following components:

Chief complaint or reason for the encounter

History of the present illness (HPI)

Review of systems (ROS)

Past family and/or social history (PFSH)

Any record format for documenting any component of the history is acceptable, including, for example, preprinted history forms that are completed by the patient, other informant, and/or ancillary staff as necessary with documentation of review by the physician or other health care professional. (There must be notation supplementing or confirming information recorded by others.) Components may be identified separately or they may be combined, for example, in the history of present illness.

Chief Complaint and/or Reason for Encounter

Document

The chief complaint and/or the reason for the encounter for all codes except subsequent inpatient hospital services.

The chief complaint/reason for the encounter can include items such as referral by another physician; lab test performance; specific complaints; physician directed return for follow-up.

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History of Present Illness

Document

The history of present illness (HPI) as follows:

Brief HPI — A description of one to three historical items about the present illness(es) or the status of one or two chronic or inactive conditions.

Extended HPI — A description of at least four items about the present illness(es) or the status of at least three acute, chronic, or inactive conditions.

Review of Systems

Document

A review of systems obtained during an earlier encounter does not need to be re-recorded. Any new ROS information should be documented, or alternatively document “no change” from previous ROS with notation of date or location of previous ROS.

The review of systems as follows:

Pertinent ROS — Positive responses and clinically relevant negatives for the system directly related to the problem(s) identified in the HPI

Extended ROS — Positive responses and clinically relevant negatives for 2–4 systems

Complete ROS — Positive responses and clinically relevant negatives for at least five systems. A notation that “all other systems negative” or “ROS negative” is adequate.

Past, Family, and/or Social History

Past history — describes that patient’s past experiences with illnesses, operations, injuries and treatments such as:

Listing/review of current medications

Allergies

Tobacco/alcohol/drug abuse

Operations

Injuries/trauma

Pregnancy history

Growth and development history

Immunization history

Behavioral/functional history

Other relevant past history

Family history — a review of medical events in the patient’s family, including diseases which may be hereditary or place the patient at risk, such as family history of:

Cardiovascular disease: stroke, myocardial infarction or other cardiovascular illness

Cancer

Alcohol/tobacco/drug abuse

Domestic violence, child abuse

Lipid disorders

Hereditary disorders

Other relevant family history

Social history — describes age appropriate past and current activities

Status of immediate and extended family

Marital status

Employment status

Occupational history

Education

Housing/source of drinking water

Financial status

Other relevant social factors

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Document

A review of past, family, and/or social history obtained during an earlier encounter does not need to be re-recorded. Any new PFSH information should be documented, or, alternatively, document “no change” from previous PFSH, with notation of date or location of previous PFSH.

The past, family, and/or social history as follows:

Pertinent PFSH — At least one item from any history area

Complete PFSH — At least one item from any two of the three history areas

Select the type of history

The chart below shows the progression of the elements required for each type of history. For detailed and comprehensive history, two of the three history categories must be met.

Type of history HPI ROS PFSH

Problem focused (brief) One to three historical items of present illness or status of one or two chronic or inactive conditions

N/A N/A

Expanded problem focused (brief)

One to three historical items of present illness or status of one or two chronic or inactive conditions

Clinically pertinent, positive and negative responses for system related to problem(s)

N/A

Detailed (Extended) At least four historical items of present illness or status of at least three acute, chronic, or inactive conditions

Two to four systems At least one item from any history area

Comprehensive (extended) At least four historical items of present illness or status of at least three acute, chronic, or inactive conditions

Positive responses and clinically relevant negatives for at least five systems

At least one item from any two of the three history areas

Examination CPT describes four types of examinations:

Problem focused

Expanded problem focused

Detailed

Comprehensive

These examinations may be a general multi-system examination, the examination of a single body area or organ system, or any combination thereof. Any examination may be performed by any physician regardless of specialty. Actual content of the examination is selected by the examining physician in accordance with the needs of the patient.

Document

Problem focused examination — document 1 to 5 exam items

Expanded problem focused examination — document 6 to 11 exam items

Detailed — document 12 to 17 exam items

Comprehensive — document 18 or more exam items (within the constraints imposed by the urgency of the patient’s mental status and/or clinical condition)

Any type of record format is acceptable, including, for example, simple “check lists” to indicate that an item has been performed.

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A brief statement or notation indicating “negative” or “normal” is sufficient to document normal findings.

Specific abnormal and clinically relevant negative findings should be documented. A notation of “abnormal” without elaboration is insufficient.

“Simplified” documentation of a single body and/or organ system is acceptable, and is equivalent to performance of a single examination. The exception being HEENT, where organ systems are examined collectively. For example, examination of the head, eyes, ear, nose, and throat, which will be equivalent to three examinations, as it includes several body systems. Further examples are listed below.

Body and/or Organ System Examination

“Simplified”Documentation

Examples

Number of Elements

HEENT (head, eyes, ears, nose, and throat)

Negative Counts as three examinations, as it includes the head, eyes, ears, nose, and throat

Chest Clear Counts as one examination item

Heart WNL Counts as one examination item

Abdomen WNL Counts as one examination item

Genitourinary WNL Counts as one examination item

Neuro Negative Counts as one examination

The following examination charts have been organized in an anatomic order. It is recognized that, depending on the physician’s specialty, and personal examination techniques, the items listed could be categorized in a different anatomic order of body area location. Accordingly, physicians may choose to create a customized list of these examination items, to more closely follow typical practice patterns.

Constitutional

Vital Signs and Measurements

Measurement of any three of the following ten vital signs(may be measured and recorded by ancillary staff):

1) sitting blood pressure, 2) standing blood pressure, 3) supine blood pressure, 4) heart rate and regularity, 5) respiratory rate, 6) temperature, 7) weight,

8) height, 9) head circumference, 10) body mass index

General appearance (includes development, nutrition, growth, color, body habitus, deformities, attention to grooming, Cushingoid Features, acromegalic features

Assessment of ability to communicate

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Head, Face, and NeckExamination Item Examples

Inspection of head and/or face Overall appearance, scars, lesions, masses

Examination of neck Overall appearance, scars, masses, torticollis, webbing, symmetryInspect/palpate for tracheal deviation

Palpation and/or percussion of face Presence or absence of sinus tenderness

Examination of salivary glands Masses, tenderness

Examination of thyroid Goiter, nodule, tenderness

Examination of fontanels Presence or absence of fullness

Examination of cranial bones and sutures Swelling, open/closed sutures

Examination of jugular veins Distention

Examination of carotid arteries Presence or absence of bruit

Examination of cervical lymphatics Enlargement of nodes in the anterior/posterior triangle, submental, supraclavicular

Eyes*Examination Item Examples

Inspection of conjunctivae, globe, and/or lids Erythema, sty, chalazion, ectropion, ptosis, xanthelsama, proptosis

Inspection of sclera

Measurement for exophthalmus Measure forward protrusion

Test visual acuity (not including determination of refractive error)

Snellen chart

Gross visual field testing including primary gaze and alignment

Nystagmus, strabismus

Examination of lacrimal glands, lacrimal drainage, and/or orbits

Swelling

Examination of pupils Reaction to light, myosis, mydriasas, anisocoria, equality

Examination of iris/irides Reaction to light, accommodation, size, and symmetry

Measurement of intraocular pressure

Ophthalmoscopic examination of optic discs and posterior segment through undilated pupils

Retinal hemorrhages, exudates, cotton-wool patches, pigmentationC/D ratio, size, atrophy, tumor, elevations

Ophthalmoscopic examination of optic discs and posterior segment through dilated pupils

Retinal hemorrhages, exudates, cotton-wool patches, pigmentationC/D ratio, size, atrophy, tumor, elevations

Slit lamp examination of the cornea(s) including epithelium, stroma, endothelium, and tear film

Bowman’s membrane, Decemet’s membrane

Slit lamp examination of the lenses including clarity, anterior and posterior capsule, cortex, and nucleus

Slit lamp examination of the anterior chambers including depth, cells, and flare

*October 1998 technical corrections made

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Ear, Nose, Mouth, and ThroatExamination Item Examples

Examination of external ears (auricles) Overall appearance, scars, lesions, masses

Otoscopic examination of external auditory canal and/or tympanic membranes

Otitis externa, otitis media

Pneumo-otoscopy Mobility of tympanic membranes

Assessment of hearing and/or clinical speech reception thresholds

Whispered voice, finger rub, tuning fork, acoustic blink reflex

Examination of external nose, nasal mucosa, septum and/or turbinate(s)

Swelling, redness, pallor, polyps, deviation, perforation

Examination of teeth and/or gums Dental caries, tooth loss, gingivitis, periodontal disease

Examination of lips and/or oral mucosa Cyanosis, pallor

Examination of oropharynx (hard and soft palates, tongue, tonsils, and/or posterior pharynx)

Lesions, torii, glosssitis, symmetry, pharyngitis

Examination by mirror of larynx, including epiglottis, pharyngeal walls and/or pyriform sinuses, false vocal cords, true vocal cords, and/or mobility of larynx

Examination by mirror, of nasopharynx (including appearance of the mucosa, adenoids, posterior choanae and eustachian tubes)

Assessment of suck reflex in infants

RespiratoryExamination Item Examples

Inspection of chest Shape, symmetry, expansion, intercostal retractions, use of accessory muscles, diaphragmatic movementAssessment of respiratory effort

Percussion of chest Dullness, flatness, hyperresonance

Palpation of chest Tenderness, masses, tactile fremitus

Ausculation of lungs Breath sounds, adventitious sounds, rubs, rales, rhonchi

CardiovascularExamination Item Examples

Palpation of heart Location, size, forcefulness of the point of maximal impact, thrills, lifts, palpable S3 or S4

Ausculation of heart Abnormal sounds, murmurs

Examination of carotid arteries Waveform, pulse amplitude, bruits, apical-carotid delay

Examination of abdominal aorta Size, bruits

Auscultation of renal arteries Pulse amplitude, bruits

Examination of femoral arteries Pulse amplitude, bruits

Examination of popliteal arteries

Examination of pedal pulses

Examination of peripheral venous system by observation and/or palpation

Swelling, varicosities, suitability of lower extremity veins for use as conduit

Examination of jugular veins Distention (JVD), A, V or cannon A waves

Examination of peripheral hemodialysis, A-V fistula Patency, status of insertion site

Measurement of ankle — brachial index

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Breasts (Chest) Examination Item Examples

Inspection of breasts (chest) Contour, symmetry, nipple discharge, inversion, retraction, Tanner stage, males – gynecomastia

Palpation of breasts Masses or lumps, tenderness

LymphaticExamination Item Examples

Palpate lymph nodes in neck LymphadenopathySubmental, cervical (anterior/posterior), supraclavicular

Palpate lymph nodes in axillae Lymphadenopathy

Palpate lymph nodes in groin Lymphadenopathy

Palpate lymph nodes of each additional lymph node area Lymphadenopathy epitrochlear, popliteal

Gastrointestinal (Abdomen)Examination Item Examples

Inspection of abdomen Obesity, distention, scars

Palpation of abdomen Masses, guarding, tenderness, presence or absences of ascites

Percussion of abdomen

Palpation of liver and/or spleen Hepatomegaly, size, tenderness, edgeSplenomegaly

Palpation of kidney Enlargement

Examination for hernia(s)

Digital anorectal examination Hemorrhoids, rectal masses, sphincter tone (including obtaining stool sample for occult blood)

Inspection of anus and perineum Condyloma, skin tags

Auscultate abdomen Bowel sounds

Genitourinary (Female)Examination Item Examples

Examination (with or without specimen collection for smears and cultures) of external genitalia

General appearance, estrogen effect, discharge, lesion(s)

Examination (with or without specimen collection for smears and cultures) of urethra and/or urethral meatus

Size, location, lesions, discharge, prolapse (masses, tenderness, scarring)

Examination of bladder Fullness, masses, tenderness

Examination (with or without specimen collection for smears and cultures) of vagina

General appearance, estrogen effect, discharge, lesion(s)

Examination (with or without specimen collection for smears and cultures) of cervix

General appearance, lesion(s), discharge

Examination of uterus Size, contour, position, mobility, tenderness, consistency, descent or support

Examination of adnexa/parametria Masses, tenderness, organomegaly, nodularity

Examination of pelvic support assessment Cystocele, rectocele, enterocele

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Genitourinary (Male)Examination Item Examples

Examination (with or without specimen collection for smears and cultures) of penis

Lesion(s), presence or absence of foreskin, plaque, masses, deformity(s), discharge

Examination (with or without specimen collection for smears and cultures) of scrotum

Lesion(s), cyst(s), rashes, hydrocele

Examination of epididymides Size, symmetry, masses

Examination of testes Size, symmetry, masses, varicocele

Examination (with or without specimen collection for smears and cultures) of urethra and/or urethral meatus

Size, location, lesions, hypospadias, masses, tenderness, scarring

Digital rectal examination of prostate Hyperplasia, enlargement, tenderness

Examination of bladder Fullness, masses, tenderness

IntegumentaryExamination Item Examples

Examination of hair of scalp, eyebrows, face, chest, pubic area (when indicated) and extremities

Hair quantity, texture, scalp, lesion(s), lump(s)

Examination of skin and subcutaneous tissues of the head and face

Color, texture, lesion(s), mole(s), birthmark(s), hair distributionHyperhidrosis, chromhidroses, bromhidrosis

Examination of skin and subcutaneous tissues of chest, including breast axillae

Color, texture, lesion(s), mole(s), birthmark(s), hair distribution Hyperhidrosis, chromhidroses, bromhidrosis

Examination of skin and subcutaneous tissues of abdomen Color, texture, lesion(s), mole(s), birthmark(s), hair distribution Hyperhidrosis, chromhidroses, bromhidrosis

Examination of skin and subcutaneous tissues of genitalia, groin, buttocks


Examination of skin and subcutaneous tissues of back Color, texture, lesion(s), mole(s), birthmark(s), hair distribution Hyperhidrosis, chromhidroses, bromhidrosis

Examination of skin and subcutaneous tissues of right upper extremity


Examination of skin and subcutaneous tissues of left upper extremity


Examination of skin and subcutaneous tissues of right lower extremity


Examination of skin and subcutaneous tissues of left lower extremity


Inspection and palpation of fingernails and/or toenails Dystrophies, mycosis, subungual tumor, infection, hematoma, psorriasis, abnormal curvature, separation or splitting

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Musculoskeletal (Lower Extremity) (Hip, Pelvis, Knee, Ankle, Foot)Examination ExampleExamination of hip and/or pelvis Scars, deformity, immobility

Range of motion (internal, external rotation, adduction, abduction, eg, Patrick’s maneuver, muscle spasm)Swelling, tenderness, decreased motion in hip joint

Examination of leg Overall appearance, masses, gross deformity, scars, trophic changes, atrophy Absence or presence of weakness in muscles, coordination, gait and stationRange of motion (internal, external rotation, supination, pronation at joints)Assessment of muscle strength and toneAbsence or presence of tenderness, swelling, misalignment, crepitation, inflammation, effusionAbsence or presence (decreased), pulses (femoral, popliteal, dorsalis pedis, posterior tibial)Assessment of temperature

Examination of knee Swelling, scars, decreased motion, inflammation, effusion, deformity (varus or valgus)Range of motion, flexion, extensionAbsence or presence of instability (ligamentous, tendinous, cartilaginous)Tenderness, pain (patellofemoral joint, suprapatellar, prepatellar bursa)

Examination of ankle Swelling, scars, growth(s) (corns, callouses), deformity (hallux valgus), massesAbsence or presence of instability (ligamentous, tendinous)Range of motion, dorsiflexion, plantar flexion, inversion, eversionTenderness over fibular/tibial, tarsal, metatarsal jointsAbsence or presence pain (ligamentous, tendinous, fibular/tibial, tarsal, metatarsal joints

Examination of foot Assessment of tendonsRange of motion of joints of the foot (eg, metatarsophalangeal, proximal phalangeal, interphalangeal, distal phalangeal joints, toes)Absence or presence of cyanosis, swelling, deformity (hammertoe, bunion), masses, inflammationAbsence of presence of tenderness over (any) calcaneous, tarsal, metatarsal, metarsophalangeal, proximal phalangeal, interphalangeal, distal phalangeal joints of the foot, toes

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Musculoskeletal (Spine) (Cervical, Thoracic, Lumbar, Sacrum)Examination Example

Examination of cervical spine Overall appearance, alignment, gross deformity (kyphosis, lordosis, scoliosis), immobility, torticollisRange of motion (rotation, lateral bending, flexion, extension), muscle spasm, trigger point(s)Swelling, masses, tenderness, decreased motion (eg, arthritis), decreased sensation, triggering, spasm

Examination of thoracic spine Overall appearance, list, masses, stature, gait, gross deformity (kyphosis, lordosis, scoliosis), immobilityAbsence or presence of weakness in spinal/peripherally innervated musclesRange of motion (rotation, lateral bending, flexion, extension), muscle spam, trigger point(s)Swelling, masses, tenderness, decreased motion (eg, arthritis), decreased sensation, triggering, spasmAssessment of spinous processes, paravertebral muscles

Examination of lumbar spine Overall appearance, list, alignment, gait, gross deformity (kyphosis, lordosis, scoliosis), immobilityAssessment of spinous processes, paravertebral musclesRange of motion (rotation, forward and lateral bending, side-to-side bending, flexion, extension)Straight-leg testing Swelling, masses, tenderness, decreased motion (eg, arthritis), decreased sensation, triggering, spasm

Musculoskeletal (Upper Extremity) (Neck, Shoulder, Elbow, Wrist, Hand)Examination Example

Examination of arm Overall appearance, gross deformity, scars, trophic changes, atrophyAbsence or presence in radially innervated musclesAbsence or presence of tenderness over radial nerve (radial tunnel or arcade of Frohse) Tinel’s sign over median nerve, antecubital fossa or forearm

Examination of shoulder Symmetry, atrophy of trapezius, supraspinatous or infraspinatous, symmetry of deltoid muscle bulkActive and passive abduction, adduction and extensionShoulder instability (anterior, posterior, or inferior)Assessment of strength (forward flexion, abduction, or extension)Absence or presence of distal paresthesias (Adson’s or Wright’s maneuver, Roos test)Absence or presence of tenderness of the levator, scapula, or acromioclavicular joint, brachial plexus, subacromial region (anteriorly, posteriorly and laterally), and proximal biceps

Examination of elbow Swelling, decreased motion Range of motion, flexion, extension, supination, pronation Absence or presence of instability (medial/lateral) epicondylitisTenderness (radiocapitellar joint, olecranon bursa)

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Musculoskeletal (Upper Extremity) (Neck, Shoulder, Elbow, Wrist, Hand) CONTINUEDExamination Example

Examination of wrist Swelling, deformity, masses Absence or presence of instability pisotriquetral, carpi ulnaris, hook of the hamate, midcarpal, or capitolunateRange of motion right and left dorsiflexion, palmar flexion, radial deviation, ulnar deviation, pronation, supinationTenderness in snuffbox or radioscaphoid, scapholunate, or radiolunate joints, ulnocarpal or distal radioulnar joints, hook of the hamate, extensor tendonsAbsence or presence of pain at lunatotriquetral or midcarpal region

Examination of hand Absence or presence of cyanosis, swelling, deformity, masses, inflammationAssessment of tendons (flexor digitorum superficialis and profundus to all fingers, flexor pollicis lungus, extensors of thumb and fingersAbsence or presence of instability of the thumb or index, long, ring, or small fingerRange of motion of joints of the thumb and fingers (abduction, adduction, metacarpophalangeal, proximal interphalangeal, distal interphalangeal)Allen test (radial/ulnar arteries), capillary refill (fingers and thumbs)Absence or presence of tenderness over (any) of joints of thumb or index, long, ring, or small fingersAbsence or presence of triggering

NeurologicExamination Item Examples

Evaluation of higher integrative function (including level of consciousness)

Orientation of time, place, recent and remote memory, attention span and concentration, language, fund of knowledge

Test cerebellar function Finger/nose, heel/knee/shin, rapid alternating movements, evaluation of fine motor coordination in children, nystagmus

Test 1st cranial nerve

Test 2nd cranial nerve (count either as neurologic or eye, not both)

Visual acuity, fields, fundi

Test 3rd, 4th and 6th cranial nerves (count either as neurologic or eye, not both)

Test 5th cranial nerve Facial sensation, corneal reflex

Test 7th cranial nerve Facial symmetry, strength

Test 8th cranial nerve (count as ear or neurologic, not both) Hearing with tuning fork, whispered voice

Test 9th cranial nerve Gag reflex, reflex palatal movement

Test 10th cranial nerve Voluntary movement of soft palate or vocal cord function

Test 11th cranial nerve Shoulder shrug strength

Test 12th cranial nerve Tongue protrussion

Evaluation for motor function Strength, muscle tone, atrophy, fasciculations

Examination of sensation Touch, pin, vibration, proprioception

Examination of deep tendon reflexes

Evaluation for abnormal and/or superficial reflexes Babinski, abdominal

Evaluation of peripheral nerves Tinel’s sign, Phalen sign

Provocative testing Adson maneuver, Lasegue maneuver

Evaluation of autonomic nervous system Bowel, bladder control

Evaluation of gait

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PsychiatricExamination Example

Description of speech Rate, volume, articulation, coherence and spontaneity

Language assessment (count as neurologic or psychiatric, not both)

Naming objects repeating phrases

Assessment of thought process Rate of thoughts, content of thoughts (logical tangential, computation)

Assessment of abstract reasoning

Assessment of association Loose, tangential, circumstantial, intact

Assessment of abnormal or psychotic thoughts Hallucinations, delusions, preoccupations with violence, homicidal or suicidal ideation, obsessions

Assessment of mood and affect (count as neurologic or psychiatric, not both)

Depression, anxiety, agitation hypomania, lability

Assessment of orientation Time, place, person

Assessment of memory (count as neurologic or psychiatric, not both)

Recent/remote

Assessment of concentration

Assessment of attention span Span

Assessment of fund of knowledge (count as neurologic or psychiatric, not both)

Awareness of current events, past history, vocabulary

Medical Decision Making

CPT describes three types of medical decision making:

Low (encompasses straightforward complexity)

Moderate complexity

High complexity

Medical decision making refers to the complexity of establishing a diagnosis and/or selecting a management option as reflected by:

The number of possible diagnoses and/or risk of complications. The risk of significant complications, morbidity and/or mortality , as well as comorbidities, associated with the patient’s presenting problem(s), the diagnostic procedure(s) and/or the possible management options

The amount and/or complexity of medical records, diagnostic tests and/or other information that must be obtained or reviewed

Management options

The following charts have been prepared to reflect the differences in physician work associated with common courses of diagnosis, review, and/or treatment decisions. These charts are provided to assist physicians in selecting the level of medical decision making that most closely resembles their own, in terms of the physician work involved. By definition, therefore, these charts are not exhaustive.

Physicians may choose the type of medical decision making by equating the patient’s clinical situation with the examples of the number of diagnoses/risk of complications, diagnostic procedures, tests and data to be reviewed, and management options. This chart, of course, does not include all possible examples of medical decision making. The highest level in any one column will determine the type of medical decision making.

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Medical Decision Making

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Type of decision making Number of diagnoses and/or risk of complications

Diagnostic procedures/tests ordered and/or amount of data to be obtained or reviewed

Management options selected

Low One or two self-limited problem(s) or symptom(s)

Non-invasive or minimally invasive lab tests (urinalysis, venipuncture, KOH, etc)

One stable chronic illness Non-invasive diagnostic procedures (EEG, ECG, ultrasound, echocardiogram)

Rest

Acute self-limited uncomplicated illness or injury

Physiologic tests not under stress

Over-the-counter drugs

Non-cardiovascular imaging studies with contrast

Physical therapy /occupational therapy

Skin biopsy

Superficial needle biopsy

Risk of complications, morbidity or mortality is low

Arterial puncture Management of one or two prescription drugs

Moderate Three or more or self-limited problems

Physiological tests under stress

Minor surgery

One or more chronic mild and/or or self-limited problem(s) with mild to moderate exacerbation, progression or side effects of treatment

Diagnostic endoscopy Management of three or more prescription drugs and/or the initiation of any new prescription drug regimen

Two or three stable chronic illnesses

Deep needle/incisional biopsy

Undiagnosed new illness, injury or problem with uncertain prognosis

Cardiovascular imaging with contrast

Therapeutic nuclear medicine

Acute illness with systemic symptoms

Obtaining fluid from body cavity

Risk of complications, morbidity or mortality is moderate. There may be an uncertain prognosis or the possibility of prolonged functional impairment with or without treatment.

Data to be obtained/reviewed requiring at least 10 minutes of physician time

Hospitalization of patient

CONTINUES

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Medical Decision Making CONTINUED

Type of decision making Number of diagnoses and/or risk of complications

Diagnostic procedures/tests ordered and/or amount of data to be obtained or reviewed

Management options

High One or more chronic illnesses with severe exacerbations

Intra-arterial cerebral angiography (excludes MRA)

Major surgery

Four or more stable chronic illnesses

Data to be obtained/reviewed requiring at least 20 minutes of physician time

Acute complicated injury

Acute or chronic illnesses that pose a threat to life or bodily function

Administration of controlled medications

Therapeutic endoscopy in a patient with risk factors

Abrupt change in bodily function (eg, seizure, CVA, acute mental status change)

Parenteral drug therapy requiring intensive monitoring and observation

Total parenteral nutrition

The risk of complications, morbidity, or mortality is high. There is a possibility of significant prolonged functional impairment.

Decision not to resuscitate or to de-escalate care because of poor prognosis

Document

In most instances, the type of medical decision making can be inferred from a properly documented medical record. It is not necessary to note the kind of decision making (ie, low, moderate, high).

Clinically relevant information, not elsewhere available in the medical record, should be documented.

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Counseling and/or Coordination of Care

When more than half of the face-to-face (office or other outpatient) or floor/unit time (hospital or nursing facility) is spent with the patient providing counseling or coordination of care, the CPT code may be selected based on the total time of the face-to-face or floor/unit time of the encounter.

Document

Length of time of the encounter

Issues discussed (brief notation)

(Relevant history, exam, and medical decision making, if performed, should also be noted in the patient’s record.)

Select the code

Select the CPT code based on the total face-to-face (office/outpatient) OR floor/unit time (hospital/nursing facility).

The following charts show the total time for the most commonly used categories of codes.

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Office or Other Outpatient ServicesNew Patient

Total Time of Face-to-Face Encounter

99201 Typically 10 minutes





Office or Other Outpatient ServicesEstablished Patient

Total Time of Face-to-Face Encounter






Initial Hospital Inpatient Service Total Floor/Unit Time




Subsequent Hospital Care Total Floor/Unit Time




When counseling or coordination of care does not dominate the encounter, select a level of service based on history, examination, and medical decision making.

Documents

Draft "New Framework" for Evaluation and Management (E/M