assignment 2 Date: Client Complexity: Comfort Assessment Episodic (Acute Condition) Multiple/Chronic/Controlled Disease Multiple/Chronic/Uncon

assignment 2

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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

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