Chief Complaint:	PROBLEM-FOCUSED	EXP PROB FOCUSED	DETAILED	COMPRE-HENSIVE
1-3 elements 4 elements or status of 3 chronic or inactive conditions H I S T O R Y	Circle appropriate entry furthest to right, under level of service
HPI (history of present illness) elements: Location Severity Timing Modifying factors Quality Duration Context Associated signs and symptoms	Brief	Brief	Extended	Extended
ROS (review of systems): Constitutional Eyes GI Integumentary Endo (wt loss, etc) Card/vasc GU (skin, breast) Hem/lymph Ears, nose Resp Musculo Neuro All/imm mouth, throat Psych “All others negative”	None	Pertinent to problem 1 system	Extended 2-9 systems	Complete 10 systems
PFSH (past medical, family, social history) areas: Past history (patient’s past experiences with illness, operations, injuries and treatments) Family history (a review of medical events in the patient’s family) Social history (an age-appropriate review of past and current activities)	None	None	Pertinent Est=1 area, New=2 areas	Complete Est=2 areas, New=3 areas
EXAM: (1995 Guidelines)	Above: Overall History level is determined by the column marked furthest to the left
Body Areas: Head, including the face Abdomen Each extremity Neck Genitalia, groin, buttocks Chest, including breasts & axillae Back, including spine	1 area or system- limited exam	2-7 areas or systems- limited exam	2-7 areas or systems- detailed or extended exam	8 or more areas or systems exam or complete exam of a single organ system
Organ Systems: Constitutional(e.g., vital signs, general appearance) Eyes Ears, nose, mouth, throat Cardiovascular Respiratory Gastrointestinal Genitourinary Musculoskeletal Skin Neurologic Psychiatric Hematologic/Lymphatic/Immunologic

C O M P L E X I T Y	A	Number of Diagnoses or Treatment Options
Problems to Exam Physician	Number X Points = Result
Self-limited or minor (stable, improved or worsening)	1	Max = 2
Est. problem (to examiner); stable, improved	1
Est. problem (to examiner); worsening	2
New problem (to examiner); no additional workup planned	3	Max = 3
New prob. (to examiner); add. workup planned	4
Bring total to line A in Final Result for Complex.	TOTAL
C	Amount and/or Complexity of Data to be Reviewed
Data to be Reviewed	Points
Review and/or order of clinical lab tests	1
Review and/or order of tests in the radiology section of CPT	1
Review and/or order of tests in the medicine section of CPT	1
Discussion of test results with performing physician	1
Decision to obtain old records and/or obtain history from someone other than patient	1
Review and summarization of old records and/or obtaining history from someone other than patient and/or discussion of case with another health care provider	2
Independent visualization of image, tracing, or specimen itself (not simply review of report)	2
Bring total to line C in Final Result for Complexity TOTAL
Final Result for Complexity (2components at or above)
A	Number diagnoses or treatment options	1 Minimal	2 Limited	3 Multiple	4 Extensive
B	Highest risk	Minimal	Low	Moderate	High
C	Amount and/or complexity of data	1 Minimal or low	2 Limited	3 Moderate	4 Extensive
Type of decision making	STRAIGHT-FORWARD	LOW COMPLEX	MODERATE COMPLEX	HIGH COMPLEX

B	Risk of Complications and/or Morbidity or Mortality
Level of Risk	Presenting Problem(s)	Diagnostic Procedure(s) Ordered	Management Options Selected
M I N I M A L	One self-limited or minor problem, e.g., cold, insect bite, tinea corporis	Laboratory tests requiring venipuncture Chest x-rays EKG/EEG Urinalysis Ultrasound, e.g., echo KOH prep	Rest Gargles Elastic bandages Superficial dressings
L O W	Two or more self-limited or minor problems One stable chronic illness, e.g., well controlled hypertension, non-insulin dependent diabetes, cataract, BPH Acute uncomplicated illness or injury, e.g., cystitis, allergic rhinitis, simple sprain	Physiologic tests not under stress, e.g.pulm. function tests Non-cardiovascular imaging studies with contras, e.g., barium enema Superficial needle biopsies Clinical laboratory tesxsts requiring arterial puncture Skin biopsies	Over-the-counter drugs Minor surgery with no identified risk factors Physical therapy Occupational therapy IV fluids without additives
M O D E R A T E	One or more chronic illnesses with mild exacerbation, progress, or side effects of treatment Two or more stable chronic illnesses Undiagnosed new problem with uncertain prognosis, e.g., lump in breast Acute illness with systemic symptoms, e.g., pyelonephritis, pneumonitis, colitis Acute complicated injury, e.g.,head injury with brief loss of consciousness	Physiologic tests under stress, e.g., cardiac stress test, fetal contraction stress test Diagnostic endoscopies with no identified risk factors Deep needle or incisional biopsy	Minor surgery with identified risk factors Elective major surgery (open, percutaneous or endoscopic) with no identified risk factors Prescription drug management IV fluids with additives Closed treatment of fracture or dislocation without manipulation
H I G H	One or more chronic illnesses with severe exacerbation, progression, or side effects of tx Acute or chronic illnesses or injuries that may pose a threat to life or bodily function, e.g., multiple trauma, acute MI, pulmonary embolus, severe respiratory distress, progressive severe rheumatoid arthritis, psychiatric illness with potential threat to self or others, peritonitis, acute renal failure, sent to ER, eminent delivery	Cardiovascular imaging studies with contrast with identified risk factors Diagnostic endoscopies with identified risk factors Discography	Elective major surgery (open, percutaneous or endoscopic) identified risk factors Emergency major surgery Parenteral controlled substances Drug therapy requiring intensive monitoring for toxicity

Bring result to Line B in Final Result-level is the highest component marked

Time: Face-to-face in outpatient setting Unit/floor in inpatient setting T I M E	If the physician documents total time and suggests that counseling or coordinating care dominates (more than 50%) the encounter, time may determine level of service. Documentation may refer to: prognosis, differential diagnosis, risks, benefits of treatment, instructions, compliance, risk reduction or discussion with another health care provider.
Does documentation reveal total time	Yes	No	If all answers are “yes”, may select level based on time.
Does documentation describe the content of counseling or coordinating care	Yes	No
Does documentation reveal that more than half of time was counseling or coordinating care	Yes	No

Minimal problem that may not require presence of physician Outpatient & Consults	New / Consults	Established
Requires 3 components in one column	Requires 2 components in one column
History	PF	EPF	D	C	C	PF	EPF	D	C
Examination	PF	EPF	D	C	C	PF	EPF	D	C
Complexity of medical decision	SF	SF	L	M	H	SF	L	M	H
Average Time (minutes) (Confirmatory consults have no average time)	10 New (99201) 15 Outpt cons (99241) Conf cons (99271)	20 New (99202) 30 Outpt Cons (99242) Conf cons (99272)	30 New (99203) 40 Outpt cons (99243) Conf cons (99273)	45 New (99204) 60 Outpt Cons (99244) Conf cons (99274)	60 New (99205) 80 Outpt cons (99245) Conf cons (99275)	5 (99211)	10 (99212)	15 (99213)	25 (99214)	40 (99215)
Level	I	II	III	IV	V	I	II	III	IV	V