assignment 2
Date:
Client Complexity:
Comfort Assessment
Episodic (Acute Condition)
Multiple/Chronic/Controlled Disease
Multiple/Chronic/Uncontrolled Disease
Single/Chronic/Controlled Disease
Single/Chronic/Uncontrolled Disease
Wellness Screening/HPDP
Immunizations
Type of Visit:
Acute/Episodic Care Other
Chronic Illness Management Visit Postpartum Visit
DOT Physical Pre- Employment Physical
Family Planning Visit Prenatal Visit
Health Maintenance Office Visit School Physical
Immunizations STD/STI Visit
IUD Placement/Check Well Child Exam
Menopause Counseling Womens Well Visit
New OB Visit
CC:
Initials:
Diagnostics: Cardiopulmonary Laboratory Radiology Screening Tools Other
Age:
Gender: M / F
Procedures and Skills:
Ethnicity:
Medications:
Minutes:
Student Level of Function:
100 75 50 25
Education:
Type of Site:
Therapeutics:
Follow up:
Referrals:
Physical Exam: Cardiac Constitutional/VS Derm Development Endocrine GI Genitalia GU Gyne HEENT
Lymph/Immuno Med Rec Musculoskeletal Neuro OB Other Pain Psych Respiratory
ICD- 10
CPT
Comments Office Visit E&M Coding Cheat Sheet
Medical Decision Making Points
Need 2 out of 3
99212 99213 99214
Problems 1 2 3
Data 1 2 3
Risk Minimal Low Moderate
Problem points
Self-limited or minor (max 2) 1
Established problem, stable or improving 1
Established problem, worsening 2
New problem, no workup planned (max 2) 3
New problem, additional workup planned 4
Data Reviewed Points
Review/order lab tests 1
Review/order x-rays 1
Review/order other tests (EKG, echo, etc) 1
Discuss test results with performing physician 1
Independent review of image, tracing 2
Decision to obtain old records 1
Review and summation of old records 2
Real World NP LLC 2020
Documentation Required for Each Level
Established patients
99212 99213 99214
HPI (history) 1-3 elements (brief) 1-3 elements (brief) >4 elements
(extended)
ROS (history) – 1 system (pertinent) 2-9 systems
(extended)
PFSH (history) – – At least 1 relevant
Physical exam 1-5 elements/ one
body area/organ
system
6 elements/ 2 organ
systems or body
areas
12 elements / 5-7
organ systems or
body areas
MDM Straightforward Low complexity Moderate
complexity
Time 10 mins 15 mins 25 mins
New patients
99203 99204 99205
HPI (history) 4+ elements 4+ elements 4+ elements
ROS (history) 2 systems 10 systems 10 systems
PFSH (history) 1 1 3
Physical exam 12 elements 18 elements 18 elements
MDM Low Moderate High
Time 30 45 60
References
https://www.aafp.org/fpm/2018/0700/p5.html
https://www.aafp.org/fpm/2003/0900/p33.html
https://www.aafp.org/fpm/2007/0100/p21.html
https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/
Downloads/eval-mgmt-serv-guide-ICN006764.pdf
Real World NP LLC 2020
https://www.aafp.org/fpm/2018/0700/p5.html
https://www.aafp.org/fpm/2003/0900/p33.html
https://www.aafp.org/fpm/2007/0100/p21.html
https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/Downloads/eval-mgmt-serv-guide-ICN006764.pdf
https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/Downloads/eval-mgmt-serv-guide-ICN006764.pdf
