Coding Guidelines

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Coding Guidelines

 
Level of Visit ​Historya ​Physical Examination ​Medical Decision–Makingb ​Timec ​
2—Problem Focused​
HPIb = 1–3
 
ROS = 0
 
PFSH = 0
1 organ system
(limited to affected body area)
Straightforward​10 min​
3—Expanded Problem Focused​
HPI = 1–3
 
ROS = 1
 
PFSH = 0
 
2–7 (limited examination of affected area plus 2–6 related areas)
Low​15 min​
4—Detailed​
HPI = 4+
 
ROS = 2–9
 
PFSH = 1 (pertinent)
2–7 (extended examination of affected areas and other systems)​Moderate​25 min​
5—Comprehensive​
HPI = 4+
 
ROS = 10+ (or 10 and "remainder negative")
 
PFSH = 2 or 3 if require all 3 factors
8+ or complete (general multisystem examination, not body areas)​High​45 min​
  
HPI, history of present illness; ROS, review of systems; PFSH, past, family, and social history.
 
aSee "History of Present Illness" chart. For ROS, ENT is one system.
bBased on level of risk, number of diagnoses, and complexity of data (need 2 out of 3 – see "Medical Decision-Making" and "Risk of Complications" charts).
cMore than 50% of time spent in face-to-face counseling (trumps all others).
 
History of Present Illness
 
  • Timing—includes time, frequency, and number of occurrences.
  • Quality—descriptive terms (eg, sharp, dull, stabbing, acute, chronic, improving).
  • Severity—measurement of discomfort, nonverbal symptoms (eg, wincing, doubled over), comparison to previous pain, and extent of process (eg, staging, grade of burn).
  • Context—where patient is when symptoms occur; what patient is doing (includes “fell from chair”).
  • Location—where on the body the signs and symptoms are located.
  • Duration—from what starting point.
  • Associated signs and symptoms—pertinent positive and negative results relating to chief complaint (non-review of systems).
  • Modifying factors—medications or treatments tried.
Medical Decision-Making
 
Level of medical decision-making is determined by 2 out of 3 of the following: ​ ​ ​
Level of Medical Decision-Making ​Risk of Complications ​No. of Diagnoses and Management Options ​Data to Be Reviewed (see “Risk of Complications” chart) ​
Straightforward​
Minimal
 
(see “Risk of Complications” chart)
1 self-limited
 
OR
 
1 established problem
<1 point
 
(see “Risk of Complications” chart)
Low​
Low
 
(see “Risk of Complications” chart)
2 self-limited/minor problems OR
 
2 established problems OR
 
1 established worsening OR
 
1 stable chronic
2 points
 
(see “Risk of Complications” chart)
Moderate​
Moderate
 
(see “Risk of Complications” chart)
1 new problem
 
(no additional workup) OR
 
3 established problems OR
 
2 established problems, 1 worsening
3 points
 
(see “Risk of Complications” chart)
High​
High
 
(see “Risk of Complications” chart)
1 new problem + additional workup
OR
 
4 established problems OR
 
2 established problems, 1 worsening
4 points
 
(see “Risk of Complications” chart)
 
Risk of Complications
 
Risk is determined by 2 out of 3 of the following: ​ ​ ​
Level of Risk ​Presenting Problems ​Diagnostic Procedures ​Management Options ​
Minimal​1 self-limited​-Laboratory test (venipuncture)​-Bandages/rest/dressing​
Low​
2 or more self-limited OR
 
1 stable chronic
OR
 
acute uncomplicated
-Radiograph (single)
 
-Physiologic test (spirometry)
 
-Superficial needle box
 
-Arterial laboratory test
-Over-the-counter drugs
 
-Minor surgery
 
-Occupational therapy
Moderate​
1 or more chronic with mild exacerbation OR
2 or more stable OR
acute with systemic symptoms OR
acute complicated OR
undiagnosed new problem with uncertain prognosis
-Multiple radiographs
 
-Computed tomography, magnetic resonance imaging
 
-Cardiothoracicimaging
 
-Lumbar puncture
 
-Joint aspiration
 
-Deep needle box
-Prescription drugs
 
-Closed fracture treatment
 
-Minor surgery with risks
 
-Elective major surgery
High​
1 or more chronic with severe exacerbation OR
 
acute illness with threat to life and limb OR
 
abrupt change in neurologic status
-Discography
 
-Myelography
 
-Arthrogram
-Elective major surgery with risks
 
-Controlled substance
 
-Drug therapy with intensive monitoring
 
Data to Be Reviewed
  
Count the number of points. ​
1 point​Order and/or review laboratory test​
1 point​Order and/or review radiology test​
1 point​Order and review other test (eg, electrocardiogram)​
1 point​Decision to obtain old records or additional history​
​ ​
2 points​Direct visualization of laboratory results or image​
2 points​Review and summarize old records​
2 points​Obtain history from other than patient​
2 points​Discuss case with other provider​
 
The recommendations in this publication do not indicate an exclusive course of treatment or serve as a standard of medical care. Variations, taking into account individual circumstances, may be appropriate. This content is for informational purposes only. It is not intended to constitute financial or legal advice. A financial advisor or attorney should be consulted if financial or legal advice is desired.
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