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

  • 1. 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.
  • 2. draft-new-framework-for-evaluation-and-management-em2854.doc 2 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 guidelines@ama-assn.org.
  • 3. draft-new-framework-for-evaluation-and-management-em2854.doc 1 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.
  • 4. draft-new-framework-for-evaluation-and-management-em2854.doc 2 Select the Level of E/M In accordance with the Evaluation and Management CPT describes four types of history: Services Guidelines for the selection of the appropriate level of E/M Services (see page 8 of CPT), all of the ¿ Problem focused key components (ie, history, examination, and medical decision making), must meet or exceed the stated ¿ Expanded problem focused requirements to qualify for a particular level of E/M service for the following new or initial patient ¿ Detailed categories/subcategories: office, new patient; hospital observation services; initial hospital care; office ¿ Comprehensive consultations; initial inpatient consultations; confirmatory consultations; emergency department Each type of history is made up, to varying degrees, of services; comprehensive nursing facility assessments; the following components: domiciliary care, new patient; and home, new patient. Two of the three key components (ie, history, • Chief complaint or reason for the encounter examination, and medical decision making) must meet or exceed the stated requirements to qualify for a • History of the present illness (HPI) particular level of E/M service for the following established or follow-up patient • Review of systems (ROS) categories/subcategories: office, established patient; subsequent hospital care; follow-up inpatient • Past family and/or social history (PFSH) consultations; subsequent nursing facility care; domiciliary care, established patient; and home, Any record format for documenting any component of established patient. the history is acceptable, including, for example, See page 15 of the guidelines when counseling or preprinted history forms that are completed by the coordination of care dominates the encounter. patient, other informant, and/or ancillary staff as necessary with documentation of review by the physician or other health care professional. (There must History be notation supplementing or confirming information recorded by others.) Components may be identified The extent of the history that is obtained is dependent on separately or they may be combined, for example, in the the physician’s clinical judgment and the nature of the history of present illness. presenting problem(s) or the reason for the encounter. Chief Complaint and/or If the physician is unable to obtain a history from the patient or other source, the record should describe the Reason for Encounter patient’s medical condition or other circumstance which precludes obtaining a history. Document This includes urgent/emergent condition(s), patient’s The chief complaint and/or the reason for the encounter inability to communicate, or the patient is at a very high for all codes except subsequent inpatient hospital level of risk, where immediate action is necessary. services. Documentation of the circumstances related to the The chief complaint/reason for the encounter can include inability to obtain a history will be deemed equivalent to items such as referral by another physician; lab test a comprehensive history. performance; specific complaints; physician directed return for follow-up.
  • 5. draft-new-framework-for-evaluation-and-management-em2854.doc 3 History of Present Illness Past, Family, and/or Social Document History Past history — describes that patient’s past The history of present illness (HPI) as follows: experiences with illnesses, operations, injuries and Brief HPI — A description of one to three treatments such as: historical items about the present illness(es) or the status • Listing/review of current medications of one or two chronic or inactive conditions. • Allergies • Tobacco/alcohol/drug abuse Extended HPI — A description of at least four items about the present • Operations illness(es) or the status of at • Injuries/trauma least three acute, chronic, or inactive conditions. • Pregnancy history • Growth and development history Review of Systems • Immunization history Document • Behavioral/functional history A review of systems obtained during an earlier • Other relevant past history encounter does not need to be re-recorded. Any new ROS information should be documented, or Family history — a review of medical events in the alternatively document “no change” from previous patient’s family, including ROS with notation of date or location of previous diseases which may be hereditary ROS. or place the patient at risk, such as family history of: The review of systems as follows: • Cardiovascular disease: stroke, myocardial Pertinent ROS — Positive responses and infarction or other cardiovascular illness clinically relevant • Cancer negatives for the system • Alcohol/tobacco/drug abuse directly related to the problem(s) identified in • Domestic violence, child abuse the HPI • Lipid disorders • Hereditary disorders Extended ROS — Positive responses and clinically relevant • Other relevant family history negatives for 2–4 systems Social history — describes age appropriate past and current activities Complete ROS — Positive responses and clinically relevant • Status of immediate and extended family negatives for at least • Marital status five systems. A notation that “all other systems • Employment status negative” or “ROS • Occupational history negative” is adequate. • Education • Housing/source of drinking water • Financial status • Other relevant social factors
  • 6. draft-new-framework-for-evaluation-and-management-em2854.doc 4 Document A review of past, family, and/or social history The past, family, and/or social history as follows: obtained during an earlier encounter does not need to be re-recorded. Any new PFSH information should Pertinent PFSH — At least one item from any be documented, or, alternatively, document “no history area change” from previous PFSH, with notation of date or location of previous PFSH. 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 N/A N/A present illness or status of one or two chronic or inactive conditions Expanded problem focused One to three historical items of Clinically pertinent, N/A (brief) present illness or status of one or positive and two chronic or inactive negative responses conditions for system related to problem(s) Detailed (Extended) At least four historical items of Two to four systems At least one item from any history present illness or status of at area least three acute, chronic, or inactive conditions Comprehensive (extended) At least four historical items of Positive responses At least one item from any two of present illness or status of at and clinically the three history areas least three acute, chronic, or relevant negatives inactive conditions for at least five systems Examination Document • Problem focused examination — document 1 ¿ CPT describes four types of examinations: to 5 exam items ¿ Problem focused • Expanded problem focused examination — document 6 to 11 exam items ¿ Expanded problem focused • Detailed — document 12 to 17 exam items ¿ Detailed • Comprehensive — document 18 or more exam ¿ Comprehensive items (within the constraints imposed by the urgency of the patient’s mental status and/or These examinations may be a general multi-system clinical condition) examination, the examination of a single body area or organ system, or any combination thereof. Any ¿ Any type of record format is acceptable, examination may be performed by any physician including, for example, simple “check lists” to regardless of specialty. Actual content of the indicate that an item has been performed. examination is selected by the examining physician in accordance with the needs of the patient.
  • 7. draft-new-framework-for-evaluation-and-management-em2854.doc 5 ¿ A brief statement or notation indicating ¿ “Simplified” documentation of a single body “negative” or “normal” is sufficient to document and/or organ system is acceptable, and is normal findings. equivalent to performance of a single examination. The exception being HEENT, ¿ Specific abnormal and clinically relevant where organ systems are examined collectively. negative findings should be documented. A For example, examination of the head, eyes, ear, notation of “abnormal” without elaboration is nose, and throat, which will be equivalent to insufficient. three examinations, as it includes several body systems. Further examples are listed below. Body and/or Organ System “Simplified” Number of Elements Examination Documentation Examples HEENT (head, eyes, ears, nose, and Negative Counts as three examinations, as it throat) 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
  • 8. draft-new-framework-for-evaluation-and-management-em2854.doc 6 Head, Face, and Neck Examination Item Examples Inspection of head and/or face Overall appearance, scars, lesions, masses Examination of neck Overall appearance, scars, masses, torticollis, webbing, symmetry Inspect/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 Snellen chart error) Gross visual field testing including primary gaze and Nystagmus, strabismus alignment Examination of lacrimal glands, lacrimal drainage, and/or Swelling orbits 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 Retinal hemorrhages, exudates, cotton-wool patches, segment through undilated pupils pigmentation C/D ratio, size, atrophy, tumor, elevations Ophthalmoscopic examination of optic discs and posterior Retinal hemorrhages, exudates, cotton-wool patches, segment through dilated pupils pigmentation C/D ratio, size, atrophy, tumor, elevations Slit lamp examination of the cornea(s) including epithelium, Bowman’s membrane, Decemet’s membrane stroma, endothelium, and tear film 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
  • 9. draft-new-framework-for-evaluation-and-management-em2854.doc 7 Ear, Nose, Mouth, and Throat Examination Item Examples Examination of external ears (auricles) Overall appearance, scars, lesions, masses Otoscopic examination of external auditory canal and/or Otitis externa, otitis media tympanic membranes Pneumo-otoscopy Mobility of tympanic membranes Assessment of hearing and/or clinical speech reception Whispered voice, finger rub, tuning fork, acoustic blink reflex thresholds Examination of external nose, nasal mucosa, septum and/or Swelling, redness, pallor, polyps, deviation, perforation turbinate(s) 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, Lesions, torii, glosssitis, symmetry, pharyngitis tonsils, and/or posterior pharynx) 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 Respiratory Examination Item Examples Inspection of chest Shape, symmetry, expansion, intercostal retractions, use of accessory muscles, diaphragmatic movement Assessment 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 Cardiovascular Examination 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/ Swelling, varicosities, suitability of lower extremity veins for or palpation 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
  • 10. draft-new-framework-for-evaluation-and-management-em2854.doc 8 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 Lymphatic Examination Item Examples Palpate lymph nodes in neck Lymphadenopathy Submental, 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, edge Splenomegaly 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 General appearance, estrogen effect, discharge, lesion(s) and cultures) of external genitalia Examination (with or without specimen collection for smears Size, location, lesions, discharge, prolapse (masses, and cultures) of urethra and/or urethral meatus tenderness, scarring) Examination of bladder Fullness, masses, tenderness Examination (with or without specimen collection for smears General appearance, estrogen effect, discharge, lesion(s) and cultures) of vagina Examination (with or without specimen collection for smears General appearance, lesion(s), discharge and cultures) of cervix 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
  • 11. draft-new-framework-for-evaluation-and-management-em2854.doc 9 Genitourinary (Male) Examination Item Examples Examination (with or without specimen collection for smears Lesion(s), presence or absence of foreskin, plaque, masses, and cultures) of penis deformity(s), discharge Examination (with or without specimen collection for smears Lesion(s), cyst(s), rashes, hydrocele and cultures) of scrotum Examination of epididymides Size, symmetry, masses Examination of testes Size, symmetry, masses, varicocele Examination (with or without specimen collection for smears Size, location, lesions, hypospadias, masses, tenderness, and cultures) of urethra and/or urethral meatus scarring Digital rectal examination of prostate Hyperplasia, enlargement, tenderness Examination of bladder Fullness, masses, tenderness Integumentary Examination Item Examples Examination of hair of scalp, eyebrows, face, chest, pubic Hair quantity, texture, scalp, lesion(s), lump(s) area (when indicated) and extremities Examination of skin and subcutaneous tissues of the head and Color, texture, lesion(s), mole(s), birthmark(s), hair face distribution Hyperhidrosis, chromhidroses, bromhidrosis Examination of skin and subcutaneous tissues of chest, Color, texture, lesion(s), mole(s), birthmark(s), hair including breast axillae 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, Color, texture, lesion(s), mole(s), birthmark(s), hair groin, buttocks distribution Hyperhidrosis, chromhidroses, bromhidrosis 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 Color, texture, lesion(s), mole(s), birthmark(s), hair extremity distribution Hyperhidrosis, chromhidroses, bromhidrosis Examination of skin and subcutaneous tissues of left upper Color, texture, lesion(s), mole(s), birthmark(s), hair extremity distribution Hyperhidrosis, chromhidroses, bromhidrosis Examination of skin and subcutaneous tissues of right lower Color, texture, lesion(s), mole(s), birthmark(s), hair extremity distribution Hyperhidrosis, chromhidroses, bromhidrosis Examination of skin and subcutaneous tissues of left lower Color, texture, lesion(s), mole(s), birthmark(s), hair extremity distribution Hyperhidrosis, chromhidroses, bromhidrosis Inspection and palpation of fingernails and/or toenails Dystrophies, mycosis, subungual tumor, infection, hematoma, psorriasis, abnormal curvature, separation or splitting
  • 12. draft-new-framework-for-evaluation-and-management-em2854.doc 10 Musculoskeletal (Lower Extremity) (Hip, Pelvis, Knee, Ankle, Foot) Examination Example Examination 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 station Range of motion (internal, external rotation, supination, pronation at joints) Assessment of muscle strength and tone Absence or presence of tenderness, swelling, misalignment, crepitation, inflammation, effusion Absence 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, extension Absence 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), masses Absence or presence of instability (ligamentous, tendinous) Range of motion, dorsiflexion, plantar flexion, inversion, eversion Tenderness over fibular/tibial, tarsal, metatarsal joints Absence or presence pain (ligamentous, tendinous, fibular/tibial, tarsal, metatarsal joints Examination of foot Assessment of tendons Range 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, inflammation Absence of presence of tenderness over (any) calcaneous, tarsal, metatarsal, metarsophalangeal, proximal phalangeal, interphalangeal, distal phalangeal joints of the foot, toes
  • 13. draft-new-framework-for-evaluation-and-management-em2854.doc 11 Musculoskeletal (Spine) (Cervical, Thoracic, Lumbar, Sacrum) Examination Example Examination of cervical spine Overall appearance, alignment, gross deformity (kyphosis, lordosis, scoliosis), immobility, torticollis Range 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), immobility Absence or presence of weakness in spinal/peripherally innervated muscles Range of motion (rotation, lateral bending, flexion, extension), muscle spam, trigger point(s) Swelling, masses, tenderness, decreased motion (eg, arthritis), decreased sensation, triggering, spasm Assessment of spinous processes, paravertebral muscles Examination of lumbar spine Overall appearance, list, alignment, gait, gross deformity (kyphosis, lordosis, scoliosis), immobility Assessment of spinous processes, paravertebral muscles Range 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, atrophy Absence or presence in radially innervated muscles Absence 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 bulk Active and passive abduction, adduction and extension Shoulder 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) epicondylitis Tenderness (radiocapitellar joint, olecranon bursa)
  • 14. draft-new-framework-for-evaluation-and-management-em2854.doc 12 Musculoskeletal (Upper Extremity) (Neck, Shoulder, Elbow, Wrist, Hand) CONTINUED Examination Example Examination of wrist Swelling, deformity, masses Absence or presence of instability pisotriquetral, carpi ulnaris, hook of the hamate, midcarpal, or capitolunate Range of motion right and left dorsiflexion, palmar flexion, radial deviation, ulnar deviation, pronation, supination Tenderness in snuffbox or radioscaphoid, scapholunate, or radiolunate joints, ulnocarpal or distal radioulnar joints, hook of the hamate, extensor tendons Absence or presence of pain at lunatotriquetral or midcarpal region Examination of hand Absence or presence of cyanosis, swelling, deformity, masses, inflammation Assessment of tendons (flexor digitorum superficialis and profundus to all fingers, flexor pollicis lungus, extensors of thumb and fingers Absence or presence of instability of the thumb or index, long, ring, or small finger Range 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 fingers Absence or presence of triggering Neurologic Examination Item Examples Evaluation of higher integrative function (including level of Orientation of time, place, recent and remote memory, consciousness) 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 Visual acuity, fields, fundi both) 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
  • 15. draft-new-framework-for-evaluation-and-management-em2854.doc 13 Psychiatric Examination Example Description of speech Rate, volume, articulation, coherence and spontaneity Language assessment (count as neurologic or psychiatric, not Naming objects repeating phrases both) 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 Depression, anxiety, agitation hypomania, lability psychiatric, not both) Assessment of orientation Time, place, person Assessment of memory (count as neurologic or psychiatric, Recent/remote not both) Assessment of concentration Assessment of attention span Span Assessment of fund of knowledge (count as neurologic or Awareness of current events, past history, vocabulary psychiatric, not both) Medical Decision Making CPT describes three types of medical decision making: The following charts have been prepared to reflect the differences in physician work associated with common ¿ Low (encompasses straightforward complexity) courses of diagnosis, review, and/or treatment decisions. These charts are provided to assist physicians in ¿ Moderate complexity selecting the level of medical decision making that most closely resembles their own, in terms of the physician ¿ High complexity work involved. By definition, therefore, these charts are not exhaustive. Medical decision making refers to the complexity of establishing a diagnosis and/or selecting a management Physicians may choose the type of medical decision option as reflected by: making by equating the patient’s clinical situation with the examples of the number of diagnoses/risk of • The number of possible diagnoses and/or risk of complications, diagnostic procedures, tests and data to complications. The risk of significant be reviewed, and management options. This chart, of complications, morbidity and/or mortality , as well course, does not include all possible examples of as comorbidities, associated with the patient’s medical decision making. The highest level in any one presenting problem(s), the diagnostic procedure(s) column will determine the type of medical decision and/or the possible management options making. • The amount and/or complexity of medical records, diagnostic tests and/or other information that must be obtained or reviewed • Management options
  • 16. draft-new-framework-for-evaluation-and-management-em2854.doc 14 Medical Decision Making Type of decision making Number of diagnoses Diagnostic Management options selected and/or risk of procedures/tests ordered complications and/or amount of data to be obtained or reviewed Low One or two self-limited Non-invasive or minimally problem(s) or symptom(s) invasive lab tests (urinalysis, venipuncture, KOH, etc) One stable chronic illness Non-invasive diagnostic Rest procedures (EEG, ECG, ultrasound, echocardiogram) Acute self-limited Physiologic tests not under Over-the-counter drugs uncomplicated illness or stress injury Non-cardiovascular Physical therapy /occupational imaging studies with therapy contrast Skin biopsy Superficial needle biopsy Risk of complications, Arterial puncture Management of one or two morbidity or mortality is prescription drugs low Moderate Three or more or self- Physiological tests under Minor surgery limited problems stress One or more chronic mild Diagnostic endoscopy Management of three or more and/or or self-limited prescription drugs and/or the problem(s) with mild to initiation of any new prescription moderate exacerbation, drug regimen progression or side effects of treatment Two or three stable chronic Deep needle/incisional illnesses biopsy Undiagnosed new illness, Cardiovascular imaging Therapeutic nuclear medicine injury or problem with with contrast uncertain prognosis Acute illness with systemic Obtaining fluid from body symptoms cavity Risk of complications, Data to be Hospitalization of patient morbidity or mortality is obtained/reviewed moderate. There may be an requiring at least 10 uncertain prognosis or the minutes of physician time possibility of prolonged functional impairment with or without treatment. CONTINUES
  • 17. draft-new-framework-for-evaluation-and-management-em2854.doc 15 Medical Decision Making CONTINUED Type of decision making Number of diagnoses Diagnostic Management options and/or risk of procedures/tests ordered complications and/or amount of data to be obtained or reviewed High One or more chronic Intra-arterial cerebral Major surgery illnesses with severe angiography (excludes exacerbations MRA) Four or more stable Data to be chronic illnesses obtained/reviewed requiring at least 20 minutes of physician time Acute complicated injury Acute or chronic illnesses Administration of that pose a threat to life or controlled medications bodily function Therapeutic endoscopy in a patient with risk factors Abrupt change in bodily Parenteral drug therapy requiring function (eg, seizure, CVA, intensive monitoring and observation acute mental status change) Total parenteral nutrition The risk of complications, Decision not to resuscitate or to de- morbidity, or mortality is escalate care because of poor high. There is a possibility prognosis of significant prolonged functional impairment. 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.
  • 18. draft-new-framework-for-evaluation-and-management-em2854.doc 16 Counseling and/or Coordination of Care When more than half of the face-to-face (office or other Document outpatient) or floor/unit time (hospital or nursing facility) is spent with the patient providing counseling or ¿ Length of time of the encounter coordination of care, the CPT code may be selected based on the total time of the face-to-face or floor/unit ¿ Issues discussed (brief notation) time of the encounter. (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. Office or Other Outpatient Services Total Time of Face-to-Face Encounter New Patient 99201 Typically 10 minutes 99202 Typically 20 minutes 99203 Typically 30 minutes 99204 Typically 45 minutes 99205 Typically 60 minutes Office or Other Outpatient Services Total Time of Face-to-Face Encounter Established Patient 99211 Typically 5 minutes 99212 Typically 10 minutes 99213 Typically 15 minutes 99214 Typically 25 minutes 99215 Typically 40 minutes Initial Hospital Inpatient Service Total Floor/Unit Time 99221 Typically 30 minutes 99222 Typically 50 minutes 99223 Typically 70 minutes Subsequent Hospital Care Total Floor/Unit Time 99231 Typically 15 minutes 99232 Typically 25 minutes 99233 Typically 35 minutes When counseling or coordination of care does not dominate the encounter, select a level of service based on history, examination, and medical decision making.