History |
Nurse’s
Assessment
Key components not needed, a service must be performed
and documented |
Chief complaint; brief
hx (1-3 elements) of present illness , or status
of 1-2 chronic conditions (1997); 0 system review |
Chief complaint; brief
hx of present illness , or status of 1-2 chronic
conditions (1997), 1 problem focused ROS |
CC, Extended hx(4> elements)
of present illness , or status of 3> chronic conditions
(1997); pertinent past /family and social history,
2-9 systems
reviewed |
CC, Extended hx of present
illness ,or status of 3> chronic conditions (1997); complete
past/family and social hx, *Est pt.
complete is 2 of 3 areas,10>systems
reviewed or pertinent systems and “all other systems
normal”. |
CC, Extended hx of present
illness , or status of 3> chronic conditions (1997); complete
past/family and social history; 10> systems reviewed or
pertinent systems and “all other systems normal”. |
Exam.
(1997 Physical DGs must count bullets for level assignment) |
Does not require presence of
provider physician |
One area of thebody
or organ system;
Multisystem, 1-5 bullets (1997) |
Limited exam of affected
body area or organ system & other symptomatic or related
organ systems (2-7);
(6-11 bullets -1997
Multisystem) |
Extended exam of affected
body area & other symptomatic or related organ systems
(2-7); 2> bulleted elements from each of 6 areas
or12> bulleted elements
in 2> areas/symptoms –(1997) |
8> areas/organs
examined; Multisystem: perform 2 bullets
in 9 systems (1997); Single system-use 1997 DGs |
8> areas/organs examined
; Multisystem: perform 2 bullets in 9 systems (1997);single
system -
use 1997 DGs |
MDM – See Risk Chart:
Severity of Presenting Problems |
Minimal |
Self-limited; minor |
Low to moderate |
Moderate |
Moderate to high |
Moderate to high |
MDM: Diagnoses or Management
Options |
Under the supervision of a provider
physician |
Minimal (one) |
Limited |
Multiple |
Multiple |
Extensive |
MDM: Amount/Complexity ofData
to be Reviewed |
|
Minimal or none |
Limited |
Moderate |
Extensive |
Extensive |
MDM: Risk of Complications |
|
Minimal |
Low |
Moderate |
High |
High |
Estimated Face-to-face time
with patient and/or family (Dominate factor if counseling/coordination
of care exceeds 50% of total F-F time) |
5 min |
10 min (new)
10 min (est)
consults :
15 min/99241
20 min/99251 |
20 min (new)
15 min (est)
consults :
30 min/99242
40 min/99252 |
30 min (new)
25 min (est)
consults :
40 min/99243
55 min/99253 |
45 min (new)
25 min (est)
consults :
60 min/99244
80 min/99254 |
60 min (new)
40 min (est)
consults :
80 min/99245
110 min/99255 |
