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A summary of the documentation of level of service requirements for medical encounters based on the 1997 Evaluation and Management Services Guidelines. This is an excerpt from the Demystifying Medical Documentation presentation.
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Created by The Lung Doctor for e-Medtools
Documentation of Level of Service Documentation of Level of Service of Medical of Medical EncountersEncounters
Created by The Lung Doctor for e-Medtools
Inpatient EncountersInpatient EncountersInitial Hospital EncounterOr ObservationRequires 3 components within shaded area
Subsequent Inpatient Or Follow upRequires 2 components
History D or C
D or C
SF/L
I9922199218
C C PF EPF D
C
M
EPF
II9922299219
DC
H H
III9922399220
III9923399263
M
II9923299262
PF
SF/L
Examination
Complexity of medical decision
LEVELInit Hosp Care Observation
I9923199261
C = Complete D = Detailed EPF = Extended problem focused H = High M = Moderate PF = Problem focused SF/L = Straight forward/LowC = Complete D = Detailed EPF = Extended problem focused H = High M = Moderate PF = Problem focused SF/L = Straight forward/Low
Adapted from CMS Medicare Part B HGSAdministrators Documentation WorksheetAdapted from CMS Medicare Part B HGSAdministrators Documentation Worksheet
Created by The Lung Doctor for e-Medtools
Outpatient, Outpatient, Consults Consults (Outpatient, Inpatient)(Outpatient, Inpatient) and ERand ER
New Office / Consult / ERRequires 3 components within shaded area
Established OfficeRequires 2 components
PF ER: PF
PF EPF D C
PF
Minimal problem that may
not require
presence of
physician
I99211
SF
D
II-212
CEPF
L
III-213
H
V-215
M
IV-214
PF ER: PF
SFER: SF
I99-20199-24199-25199-281
History EPFER: EPF
DER: EPF
CER: D
CER: C
EPFER: EPF
SFER: L
CER: D
II-202-242-252--282
CER: C
DER: EPF
LER: M
HER: H
III-203-243-253-283
V-205-245-255-285
MER: M
IV-204-244-254-284
Examination
Complexity of medical decisionLEVELNew PtOutpt ConsultInpt ConsultER
Adapted from CMS Medicare Part B HGSAdministrators Documentation WorksheetAdapted from CMS Medicare Part B HGSAdministrators Documentation Worksheet
Created by The Lung Doctor for e-Medtools
Documenting Time Documenting Time As a Determinant of Level of ServiceAs a Determinant of Level of Service
“If the physician documents total time and suggests that counseling or coordinating care dominates (more than 50%) the encounter, time may determine level of service. Documentation may refer to: prognosis, differential diagnosis, risks, benefits of treatment, instructions, compliance, risk reduction or discussion with another health care provider.”
Does documentation reveal total time?Time: Face to face in outpatient setting
Unit/floor in inpatient setting
□Yes □No
Does documentation describe the content of counseling or coordinating care □Yes □No
Does documentation reveal that more than half the time was counseling or coordinating care? □Yes □No
Documentation of Time requires that ALL of the answers to the above questions are YES
Adapted from CMS Medicare Part B HGSAdministrators Documentation WorksheetAdapted from CMS Medicare Part B HGSAdministrators Documentation Worksheet
