| 2—Problem Focused | HPIb = 1–3 ROS = 0 PFSH = 0 | 1 organ system (limited to affected body area) | Straightforward | 10 min |
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| 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 |
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| 4—Detailed | HPI = 4+ ROS = 2–9 PFSH = 1 (pertinent) | 2–7 (extended examination of affected areas and other systems) | Moderate | 25 min |
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| 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 |
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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
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).
Medical Decision-Making
| Level of Medical Decision-Making | Risk of Complications | No. of Diagnoses and Management Options | Data to Be Reviewed (see “Risk of Complications” chart) |
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| Straightforward | Minimal (see “Risk of Complications” chart) | 1 self-limited OR 1 established problem | <1 point (see “Risk of Complications” chart) |
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| 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) |
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| 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) |
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| 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) |
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Risk of Complications
| Level of Risk | Presenting Problems | Diagnostic Procedures | Management Options |
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| Minimal | 1 self-limited | -Laboratory test (venipuncture) | -Bandages/rest/dressing |
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| 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 |
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| 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 |
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| 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 |
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Data to Be Reviewed
| 1 point | Order and/or review laboratory test |
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| 1 point | Order and/or review radiology test |
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| 1 point | Order and review other test (eg, electrocardiogram) |
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| 1 point | Decision to obtain old records or additional history |
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| |
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| 2 points | Direct visualization of laboratory results or image |
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| 2 points | Review and summarize old records |
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| 2 points | Obtain history from other than patient |
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| 2 points | Discuss case with other provider |
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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.