Document Name: NHIC Evaluation & Management Coding Worksheets NHIC Doc.

Number: TMP-MDR-0103

Release Date: 12/10/2008 Version: 8.0

Code Billed: Consult: Yes No If yes, ALL 3 must be documented (Request Report Recommendation )

Chief Complaint: Bene Initials: _______ D.O.S. _____________

HPI (history of present illness) elements:
Location Duration Modifying Factors
Where is problem? Onset of .symptoms to What have you done to alleviate or Brief Extended
present. worsen symptoms? 1-3 HPI elements > 4 HPI elements or
Severity Timing Associated Signs/Symptoms status of ≥ 3 chronic
How bad on a scale 1/10 When/how often What else is bothering you? or inactive conditions

Quality Sharp/dull/ hot/dry Context What are you doing when sxs occurs?
ROS (Review of Systems)
None 1 ROS Extended Complete
Constitutional Card/Vasc Musculo Psych “All Others 2-9 ROS ≥ 10 ROS or
Negative” some
Eyes Respiratory Integument Endo systems +
HISTORYHISTORY

statement
Ears, Nose GI GU Hem/Lymph “all others
Mouth, Throat negative”
Neuro Allerg/Imm.
No PFSH is required: Subsequent Hospital and Subsequent Nursing
Facility Care services require an interval history only. Established/
Subsequent None 1 PFSH 2 PFSH
Past History (the pt’s past experiences w/illnesses, operations, injuries,
treatments, medications & allergies) *E.D.
Family History (review of medical events in the pt’s family including diseases
which are hereditary or put the pt at risk) New or None 1-2 3
Initial PFSH PFSH
Social History (an age appropriate review of past and current activities)

Circle the entry farthest to the right for each history area. To determine history level, draw a line down
the column with the circle farthest to the left. EXP.
PROB. PROB. COMPRE-
Important Note: Allow a comprehensive history if the physician is unable to obtain a history FOCUSED FOCUSED DETAILED HENSIVE
from the patient or other source. The record should describe the patient’s condition or
circumstance that precludes obtaining history. PF EPF D C
*99281-99285: No distinction is made between new & established patients in the E.D.
1997 Guidelines - General Multi System 1997 Guidelines - Single Organ System Exam Level
1-5 elements identified by • 1-5 elements identified by • PROBLEM FOCUSED (PF)
≥ 6 elements identified by • ≥ 6 elements identified by • EXPANDED PF (EPF)

≥ 2 elements identified by • from any 6 areas/systems ≥ 12 elements identified by • EXCEPT

OR ≥12 elements identified by • from ≥2 areas/systems ≥ 9 elements identified by • for eye & psych exams DETAILED (D)
≥ 2 elements identified by • from 9 areas/systems Document all elements in bolded outlined system boxes and COMPREHENSIVE (C)
≥ 1 element in unbolded system boxes
Affected Body Areas (BA) Organ Systems (OS) 1995 Guidelines
Head/Face Constitutional Skin
1 (BA) or 2-7 (OS) 2-7 (OS) 8 or more
(OS) and/or (BA) and/or (BA) (OS)
EXAM

Neck Eyes Neuro

(Extended (A general
Abdomen Ears, nose, mouth, throat Psych
(Limited (Limited exam of multisystem
exam of exam of affected exam or
Chest + breast / axillae Cardiovascular Hem/Lymph/Immune affected BA affected BA BA(s) and complete
or OS) or OS and other or exam of a
other related single
Genital/groin/buttocks Respiratory
symptomatic OS(s)) organ
or related system)
Back, include spine GI
OS(s))
Extremity/(ies) L / R Upper GU
PF EPF D C
L / R Lower Musculo

The master copy of this document is stored in the NHIC ISO Documentation Repository. Any other copy, either electronic or paper is an uncontrolled copy and must be deleted or destroyed when it has served its
purpose.
Document Name: NHIC Evaluation & Management Coding Worksheets NHIC Doc. Number: TMP-MDR-0103

Release Date: 12/10/2008 Version: 8.0

A Presenting Problems to the Treating Provider B Amount and/or Complexity of Data to be Reviewed Pts.
(# Diags Require Active Management or Affect Treatment Options)
Points = Result Review or order of clinical lab tests 1
Self limited / minor (stable, improved or worse) Max = 2 1 Review or order of tests in the radiology section of CPT 1
Est. problem (stable, improved) Max = 2 1 Review or order of tests in the medicine section of CPT 1
Est. problem (worsening) Max = 2 2 Discussion of test results with performing physician 1
New problem (to Provider) (no add’l workup) Max=1 3 Decide to obtain old records or to obtain history from someone else 1
New problem (to Provider) (additional workup) Max=1 4 Review & summarize old records or get Hx from someone or talk with
other provider 2
Independent visualization of image, tracing or specimen itself (not
Bring total to Line A in Final Result for Complexity TOTAL simply review of the paper copy report) 2
Bring total to Line B in Final Result for Complexity TOTAL

C Risk of Complications / Morbidity / Mortality: Check off all that apply. The highest level of risk in any one column determines the overall risk.
Level Presenting Problem(s) Diagnostic Procedure(s) Ordered Management Options Selected

• One self-limited or minor problem, e.g., cold, • Laboratory tests requiring venipuncture • Rest
MINIMAL

insect bite, tinea corporis • Chest x-rays, KOH prep or EKG/EEG • Gargles
• Urinalysis or Ultrasound e.g., echo • Elastic bandages
• Potassium Dydroxide prep etc. • Superficial dressings
DECISION MAKING

• Two or more self-limited or minor problems • Physiologic test not under stress e.g., pulm. • Over the counter drugs
• One stable chronic illness e.g., well controlled function tests • Minor surgery with no identified risk
hypertension, non-insulin dependent diabetes, • Non-cardiovascular imaging studies with factors
LOW

cataract, BPH contrast e.g., barium enema • Physical therapy

• Acute uncomplicated illness or injury e.g., • Superficial needle biopsies or Skin biopsies • Occupational therapy
cystitis, allergic rhinitis, simple sprain • Clinical laboratory tests requiring arterial • IV fluids without additives
puncture
• One or more chronic illnesses with mild • Physiologic test under stress e.g., cardiac • Minor surgery with identified risk factors
exacerbation, progression or side effects of stress test, fetal contraction stress test • Elective major surgery (open percutaneous
treatment • Diagnostic endoscopies with no identified or endoscopic) with no identified risk
MODERATE

• Two or more stable chronic illnesses risk factors factors)

• Undiagnosed new problem with uncertain • Deep needle or incisional biopsy • Prescription drug management
prognosis e.g., lump in breast • Caridovascular imaging studies with contrast • Therapeutic nuclear medicine
• Acute illness with systemic symptoms e.g., and no identified risk factors e.g., • IV fluids with additives
pyelonephritis pneumonitis, colitis arteriogram, cardiac cath • Closed treatment of fracture or dislocation
• Acute complicated injury e.g., head injury with • Obrtain fluid from body cavity e.g., lumbar without manipulation
brief loss of consciousness puncture, thoracentesis, culdocentesis
• One or more chronic illnesses with severe • Cardiovascular imaging studies with contrast • Elective major surgery (open, percutaneous
exacerbation, progression or side effects of with identified risk factors or endoscopic) with identified risk factor
treatment • Cardiac electophysiological tests • Emergency major surgery (open,
• Acute or chronic illnesses or injuries that may • Diagnostic endoscopies with identified risk percutaneous or endoscopic)
pose a threat to life or bodily function e.g., factors • Parenteral controlled substances
HIGH

multiple trauma, acute MI, pulmonary embolus, • Discography • Drug therapy requiring intensive monitoring
severe respiratory distress, progressive severe for toxicity
rheumatoid arthritis, psychiatric illness • Decision not to resuscitate or de-escalate
w/potential threat to self or others, peritonitis, care because of poor prognosis
acute renal failure
• An abrupt change in neurological status e.g.,
seizure, TIA, weakness, sensory loss

A Circle the Total number in section A ≤ 1 Minimal 2 Limited 3 Multiple ≥ 4 Extensive

B Circle the Total number in section B ≤ 1 Minimal or None 2 Limited 3 Multiple ≥ 4 Extensive
C Circle the Level in section C Minimal Low Moderate High
Complexity Level of Medical Decision Making (Mdm) STRAIGHTFORWARD SF LOW L MODERATE M HIGH H
Draw a line down the column with 2 or 3 circles and circle decision making level OR Draw a line down the column with the center circle = level of Mdm
If the physician documents total time and suggests that counseling or coordinating care dominates (greater than 50%) the
encounter, time may determine level of service. Documentation may refer to: prognosis, differential diagnosis, risks, benefits of
treatment, instructions, compliance, and/or risk reduction. If both answers are
TIME

Does documentation reveal total time? Time: Face-to-face outpatient setting Yes No “yes,” you may
Unit/floor in inpatient setting select the level
Does documentation describe the content of counseling or coordinating care? Yes No based on time.

The master copy of this document is stored in the NHIC ISO Documentation Repository. Any other copy, either electronic or paper is an uncontrolled copy and must be deleted or destroyed when it has served its
purpose.
Document Name: NHIC Evaluation & Management Coding Worksheets NHIC Doc. Number: TMP-MDR-0103

Release Date: 12/10/2008 Version: 8.0

PLEASE NOTE: Time factors are indicated by CPT code followed by –xx (example: 99201-10 indicates 10 minutes)
Directions: Transfer the history, exam and medical decision making results to the correct chart below & follow the instructions for that
Code family

New Office/Outpatient Visits & Office/Inpatient Consultations Established Patient Office/Outpatient Visits
Draw a line down the column which has a key If a column has 2 or 3 circles, draw a line down the column and
component identified which is the farthest to the left circle the code OR draw a line down the column with the
Level (leveled by the lowest) center circle and circle the code

Minimal
HX PF EPF D C C problem
PF EPF D C
that may
not
require
EX PF EPF D C C presence
PF EPF D C
of MD/DO
MDM SF SF L M H SF L M H

CPT Code 99201-10 99202-20 99203-30 99204-45 99205-60 99211-5 99212-10 99213-15 99214-25 99215-40
99241-15 99242-30 99243-40 99244-60 99245-80
99251-20 99252-40 99253-55 99254-80 99255-110

Initial Hosp. Visits & Observation Care Subsequent Hosp.

Draw a line down the column which has a key If a column has 2 or 3 circles, draw a line down the column and
component identified which is the farthest to the left circle the code OR draw a line down the column with the
(leveled by the lowest) center circle and circle the code
Level These are PER DAY CODES This is a PER DAY CODE

HX D or C C C PF interval EPF interval D interval

EX D or C C C PF EPF D

MDM SF/L M H SF/L M H

CPT Code 99221-30 99222-50 99223-70 99231-15 99232-25 99233-35

99218 99219 99220
99234 99235 99236

EMERGENCY CARE SERVICES

Draw a line down the column which has a key component identified which is the farthest to the left (leveled by the lowest)

HX PF EPF EPF D C

EX PF EPF EPF D C

MDM SF L M M H

CPT Code 99281 99282 99283 99284 99285

Abbreviation Legend:
CC = Chief Complaint ROS = Review of System PFSH = (Past, Family, Social) History
HX = History EX = Exam Mdm = Medical Decision Making
PF = Problem Focused EPF = Expanded Problem Focused D = Detailed C = Comprehensive
SF = Straightforward L = Low M = Moderate H = High

Additional Comments: ______________________________________________________________________________________

The master copy of this document is stored in the NHIC ISO Documentation Repository. Any other copy, either electronic or paper is an uncontrolled copy and must be deleted or destroyed when it has served its
purpose.
Document Name: NHIC Evaluation & Management Coding Worksheets NHIC Doc. Number: TMP-MDR-0103

Release Date: 12/10/2008 Version: 8.0

Directions: Transfer history, exam and medical decision making results to appropriate chart below and follow the specific instructions
for chart.

The Nursing Facility Care Codes are PER DAY CODES, time factors effective 2008

Initial Nursing Facility Care Subsequent Nursing Facility Care

Draw a line down the column which has a key If a column has 2 or 3 circles, draw a line down the column and
component identified which is the farthest to the circle the code OR draw a line down the column with the
Level left (leveled by the lowest) center circle and circle the code

HX D C C PF EPF D C
interval interval interval interval

EX D C C PF EPF D C

MDM L M H SF L M H

CPT Code 99304-25 99305-35 99306-45 99307-10 99308-15 99309-25 99310-35

New Patient Home/Domiciliary/Custodial/Rest Home Etc. Established Home/Domiciliary/Custodial/Rest Home Etc.

Draw a line down the column which has a key component If a column has 2 or 3 circles, draw a line down the column and
identified which is the farthest to the left (leveled by the circle the code OR draw a line down the column with the
lowest). center circle and circle the code

HX PF EPF D C C PF EPF D C
interval interval interval interval

EX PF EPF D C C PF EPF D C

MDM SF SF L M H SF L M M to H
99341-20 99342-30 99343-45 99344-60 99345-75 99347-15 99348-25 99349-40 99350-60
CPT Code 99324-20 99325-30 99326-45 99327-60 99328-75 99334-15 99335-25 99336-40 99337-60

Abbreviation Legend:
CC = Chief Complaint ROS = Review of System PFSH = (Past, Family, Social) History
HX = History EX = Exam Mdm = Medical Decision Making
PF = Problem Focused EPF = Expanded Problem Focused D = Detailed C = Comprehensive
SF = Straightforward L = Low M = Moderate H = High

Additional Comments: _______________________________________________________________________________________________________________________

The master copy of this document is stored in the NHIC ISO Documentation Repository. Any other copy, either electronic or paper is an uncontrolled copy and must be deleted or destroyed when it has served its
purpose.