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Last Modified: 2/10/2018 Location: FL, PR, USVI Business: Part A, Part B

E/M interactive worksheet: Help guide

Introduction

Evaluation and management (E/M) services refer to visits furnished by physicians or non-physician practitioners. Billing Medicare for a patient visit requires the selection of the code that best represents the level of E/M service that was performed and effectively documented in the patient’s medical record. The Centers for Medicare & Medicaid Services (CMS) specifies performance and documentation requirements in the 1995 and 1997 Documentation Guidelines for Evaluation and Management Services.
Due to the subtle differences between the 1995 and 1997 sets of E/M documentation guidelines, many providers have found it challenging to select the appropriate E/M code when billing for Medicare services that have been furnished by physicians or non-physician practitioners. First Coast Service Options Inc. (First Coast) created the E/M interactive worksheet to help take some of the guesswork out of “building a code” by automatically calculating a suggested E/M code based upon the user’s entries and preferred set of guidelines.
Note: For billing Medicare, a provider may choose either version of the documentation guidelines, not a combination of the two, to document a patient encounter. However, beginning for services performed on or after September 10, 2013, physicians may use the 1997 documentation guidelines for an extended history of present illness along with other elements from the 1995 guidelines to document an evaluation and management service. Note the calculations performed by the E/M interactive worksheet and any E/M code suggested are based upon the selection of one set of E/M documentation guidelines for all key components and their associated elements.

Intuitive interface and customizable options

Even individuals working within the same office or facility may have different needs and preferences regarding which set of guidelines to use (i.e., 1995 or 1997), in which language they prefer to view information (i.e., English or Spanish), and even how the E/M interactive worksheet is to be utilized (e.g., checklist, QA or E/M coding tool, educational resource).
To address these issues, the E/M interactive worksheet has incorporated the following features into its design:
Select preferred guidelines option -- users may choose to “build an E/M code” based upon either the 1995 or 1997 E/M documentation guidelines. The options presented (e.g., 1995 and/or 1997 Examination sections) will automatically adjust based upon the user’s selection. However, if the Both ’95 and ’97 Guidelines option is selected, all required sections of the E/M interactive worksheet -- including both the 1995 and 1997 Examination sections -- must be completed in order for the worksheet to calculate the suggested E/M code correctly.
English and Spanish versions -- users may choose either version of the E/M interactive worksheet -- English or Spanish -- to view the interface, instructions, E/M tooltips, and results in his or her preferred language.
E/M Tooltips -- when making your selections in the History, Examination, and Medical Decision Making sections, you may use your cursor to reveal E/M Tooltips that will help guide you. Each E/M Tooltip is based upon either the 1995 or 1997 E/M documentation guidelines and is presented in context to the option selected.
Interactive form interface -- the overall design and features incorporated into the worksheet makes it ideal for use as an electronic checklist by physicians; an educational resource for E/M coding instructors; and as a quality assurance tool by auditors, billing specialists, and coders.

User agreement

Before beginning an E/M interactive worksheet session, you must first accept the terms of the E/M interactive worksheet: User agreement. Although the E/M interactive worksheet was created as a resource to assist providers with selecting the appropriate E/M code, it is not intended to serve as a replacement for the 1995 and 1997 E/M documentation guidelines published by CMS.
E/M interactive worksheet: User agreement
Note: Once you have acknowledged and accepted the terms of the user agreement, you will gain immediate access to the E/M interactive worksheet.

JavaScript required

In order to take advantage of the full functionality of the E/M interactive worksheet, your Internet browser must be set to enable JavaScript. If JavaScript has been disabled in your browser’s security settings, the following message will appear:
JavaScript disabled message
If JavaScript has been disabled in your Internet browser, it will be necessary to change your browser’s security settings to enable “Active scripting.” The following instructions pertain to Internet Explorer users:
JavaScript settings
Note: If you cannot change your browser’s security settings to enable “Active Scripting,” you also have the option of using the non-interactive version pdf file of the E/M worksheet. Although the non-interactive E/M worksheet will not automatically calculate a suggested E/M code for you, it may be used as either a checklist or as a reference document to help you manually select the correct code.

Preparing to use the E/M interactive worksheet

Since the E/M worksheet is designed to be interactive, your selections will directly affect the calculation of the suggested E/M code. Therefore, before beginning your E/M interactive worksheet session, it is strongly recommended that you have the following available:
Patient’s medical record
Current Procedural Terminology (CPT) manual
Note: The E/M interactive worksheet may not be used as a substitute for medical documentation within the patient’s record; however, it may be used to calculate a suggested E/M code based upon the documentation included within the medical record and the user’s preferred set of guidelines.

Step 1: Enter patient information

The focus of this section of the E/M interactive worksheet is the patient. Using the patient’s medical record as a reference, enter the following information:
First name
Last name
Date of birth
Date of service
Chief complaint (CC) or purpose of the patient’s visit
Patient information section

Step 2: Select preferred guidelines -- required section

Since the 1995 and 1997 guidelines each specify different criteria to determine the level of E/M service performed, only one set of guidelines may be used to document a specific patient visit. The E/M interactive worksheet offers providers the option to select either one set of guidelines (1995 or 1997) or both for the purpose of comparison.
Note: The primary difference between the 1995 and 1997 E/M documentation guidelines pertains to the requirements to qualify for specific Examination levels.
Each set of guidelines also specifies different requirements regarding possible examination types as well as criteria for each Examination level. These differences will be outlined in the examination section of this guide.
Guidelines selection
Options available:
Both ’95 and ’97 Guidelines (default) -- if this option is selected, the E/M interactive worksheet will display History and Examination choices, E/M Tooltips, and requirements pertaining to both sets of E/M documentation guidelines.
Note: If this option is selected, all sections of the E/M interactive worksheet -- including both the 1995 and 1997 Examination sections -- must be completed in order for the worksheet to calculate the suggested E/M code correctly. In addition, the At least 4 Associated Comorbidities option and the At least 3 Chronic/Inactive Conditions option in the HPI subsection will both be displayed.
’95 Guidelines only -- if this option is selected, the E/M interactive worksheet will display only History and Examination choices, E/M Tooltips, and requirements pertaining to the 1995 Documentation Guidelines for Evaluation & Management Services. The calculation of the suggested E/M code will be based exclusively on the user’s selections and the 1995 guidelines.
Note: If this option is selected, the 1997 Examination section, the At least 3 Chronic/Inactive Conditions option in the HPI subsection, and all associated 1997 E/M Tooltips will not be displayed.
’97 Guidelines only -- if this option is selected, the E/M interactive worksheet will display only History and Examination choices, E/M Tooltips, and requirements pertaining to the 1997 Documentation Guidelines for Evaluation and Management Services. The calculation of the suggested E/M code will be based exclusively on the user’s selections and the 1997 guidelines.
Note: If this option is selected, the 1995 Examination section, the At least 4 Associated Comorbidities option in the HPI subsection, and all associated 1995 E/M Tooltips will not be displayed.
Tip: Although the default option is Both ’95 and ’97 Guidelines, it is recommended that only one set of guidelines (1995 or 1997) is selected to avoid confusion.

Step 3: Determine level of E/M services -- required section

To determine the appropriate level of service for a patient's visit, it is necessary to first determine whether the patient is new or already established. The physician then uses the presenting illness as a guiding factor and his or her clinical judgment about the patient's condition to determine the extent of service to be performed. The key components of this determination are History, Examination, and Medical Decision Making.
Determining level of E/M Services
The Determining Level of E/M Services section defines the category of patient visit and not only determines how many of the key components must be performed and documented but also the specific requirements, as specified in both the 1995 and 1997 documentation guidelines, for the PFSH element of the History component.
In the Determining Level of E/M Services section, your selection should be based upon the following information (as indicated within the patient’s medical record):
Place of service (e.g., office, outpatient, hospital, nursing facility, rest home, home)
Type of patient (e.g., new, established) or nature of the visit (e.g., initial, subsequent, inpatient, observation)
Number of key components performed and documented (e.g., History, Examination, and Medical Decision Making)
Note: Since the 1995 and 1997 E/M documentation guidelines specify different PFSH requirements based on the category of patient visit, the Determining Level of E/M Services section should be completed before making selections within the History section.

Using the “Consultation -- Reported as . . .” options

Effective January 1, 2010, providers must report each E/M service, including those that would formerly have been reported as consultations, with an E/M code that identifies both the location of the patient’s visit and the complexity of the service performed and documented. However, although CMS has eliminated the use of CPT consultation codes for payment of E/M services furnished to Medicare fee-for-service patients, evaluation and management services continue to be covered when medically reasonable and necessary.
Since consultation codes are no longer accepted for Medicare services, providers should select the E/M code that most accurately describes not only the place of service but also the level of service performed during the patient’s visit. According to CR 6740 external link to pdf, any physician or qualified nurse practitioner who performs an initial evaluation in the inpatient hospital setting or nursing facility setting may bill an initial hospital care visit code (CPT code 99221-99223) or initial nursing facility care visit code (CPT code 99304-99306) appropriate to the location and level of service provided. However, if the service provided does not meet the criteria for the lowest level of service for initial hospital care or initial nursing facility care, 99221 and 99304 respectively, the service should be billed using the subsequent hospital care code or subsequent nursing facility care code appropriate to the location and level of service provided.
In addition, if the consultation took place in the consultant’s office, he or she should bill using a new patient office visit code (CPT code 99201-99205) or an established patient office code (CPT code 99211-99215) appropriate to the level of service provided.
Note: For your convenience, the E/M interactive worksheet includes the following options in the Determining Level of E/M Services section for those situations in which a consultation code may have been used in the past:
Consultation -- Reported as Initial Hospital Care
Consultation -- Reported as Subsequent Hospital Care
Consultation -- Reported as Initial Nursing Facility Care
Consultation -- Reported as Subsequent Nursing Facility Care
The suggested E/M code will be automatically calculated based upon the category of visit selected in the Determining Level of E/M Services section, your entries in required sections of the worksheet, and your preferred set of E/M documentation guidelines.

Step 4: Determine History level (overview) -- required section

The History section is comprised of three subsections:
History of present illness (HPI) -- a chronological description of the development of the patient’s present illness from the first sign and/or symptom or from the previous encounter to the present.
Review of systems (ROS) -- an inventory of body systems obtained by asking a series of questions in order to identify signs and/or symptoms that the patient may be experiencing or has experienced.
Past medical history, family history, social history (PFSH) -- a review of the patient’s past medical history (e.g., previous illnesses, injuries, operations), family history (e.g., potential hereditary conditions), and an age-appropriate review of patient’s social history (current and past activities).
History section
The total History level will be automatically calculated by the E/M interactive worksheet based upon choices made in each subsection (e.g., HPI, ROS, and PFSH), the Guidelines Selection section, and the Determining Level of E/M Services section.
The 1995 and 1997 E/M documentation guidelines specify the following requirements to determine the total level of History:

History level: 3 out of 3 element levels must be met or exceeded

HPI
ROS
PFSH
History Level
Brief
N/A
N/A
Problem Focused
Brief
Problem Pertinent
N/A
Expanded Problem Focused
Extended
Extended
Pertinent
Detailed
Extended
Complete
Complete
Comprehensive
Note: Levels for three out of three History elements (i.e., HPI, ROS, and PFSH) must meet or exceed the requirements specified for each level of History (i.e., Problem Focused, Expanded Problem Focused, Detailed, or Comprehensive).

HPI -- history of present illness

HPI subsection showing E/M Tooltip
The options available within the HPI subsection of the E/M interactive worksheet differ based upon the user’s preferred set of guidelines, as indicated by his or her choice in the Guidelines Selection section. If both sets of guidelines are selected, both 1995 and 1997 options will appear (as shown in the image above).
There are two possible levels of HPI:
Brief -- 1995 and 1997 E/M documentation guidelines -- at least one to three elements of the present illness must be documented in the medical record.
Extended -- either four or more elements of the present illness or four or more associated comorbidities or the status of three or more associated chronic or inactive conditions must be documented in the medical record.
Your selections in the HPI subsection should be based on the documentation contained within the patient’s medical record that describes the details surrounding the chronological development of the present illness, from the first sign or symptom of the illness to its status at the time of the visit being documented. While making your selections, use your cursor to reveal E/M Tooltips that will help you identify the quantifying elements of the HPI.
The HPI level will be automatically calculated by the E/M interactive worksheet based upon the entries within this subsection as well as the guidelines selected (1995, 1997, or both).

ROS -- review of systems

ROS with Tooltip
The options available within the ROS subsection of the E/M interactive worksheet are identical regardless of the guidelines selected. There are four possible levels of ROS:
N/A -- no inquiries regarding the system directly related to the symptom(s) identified in the HPI or any other system are documented in the medical record.
Problem Pertinent -- inquiries regarding the system directly related to the symptom(s) identified in the HPI are documented in the medical record.
Extended -- inquiries regarding the system directly related to the symptom(s) identified in the HPI and between two and nine additional systems are documented in the medical record.
Complete -- inquiries regarding the system directly related to the symptom(s) identified in the HPI and all additional systems are documented in the medical record.
Note: A total of at least ten organ systems should be reviewed and documented.
Your selections in the ROS subsection should be based on those details contained within the patient’s medical record that describe the series of questions asked by the physician (along the with the patient’s pertinent positive and negative responses) that help identify signs and/or symptoms the patient has experienced and provide an inventory of affected systems. While making your selections, use your cursor to reveal E/M Tooltips that will help you identify the systems reviewed and documented within the patient’s medical record.
The ROS level will be automatically calculated by the E/M interactive worksheet based upon the entries within this subsection.

PFSH -- past medical, family, social history

PFSH subsection with E/M Tooltip
Although PFSH is one of the easiest elements of History to document, determining the appropriate level of PFSH can cause some confusion even among experienced coders. The primary reason for the confusion is that although both the 1995 and 1997 E/M documentation guidelines specify the same requirements to determine the level of PFSH, the requirements for each level differ based upon the category of visit being documented.
There are three possible levels of PFSH:
N/A -- no inquiry or review of any of the three PFSH areas is documented in the medical record.
Pertinent -- a review of at least one specific item from any of the three PFSH areas directly related to the problem(s) identified in the HPI is documented in the medical record.
Complete -- a review of two or all three of the PFSH areas -- depending upon the category of E/M service -- is documented in the medical record.
The 1995 and 1997 guidelines both specify the following: A review of all three history areas is required for services that by their nature include a comprehensive assessment or reassessment of the patient. The E/M documentation guidelines also specify which categories of visits require comprehensive assessments as well as three out of three PFSH elements to be documented within the medical record to attain a Complete level of PFSH:
New Patient -- Office or Other Outpatient Services
Initial Observation Care
Initial Hospital Care
Observation or Inpatient Care Services -- Including Admission and Discharge
Initial Nursing Facility Care
Annual Nursing Facility Assessment
New Patient -- Domiciliary, Rest Home, or Custodial Care Services
New Patient -- Home Care Services
Your selections in the PFSH subsection should be based on those details contained within the patient’s medical record that describe the physician’s review of the patient’s past medical history (e.g., previous illnesses, injuries, operations), family history (e.g., potential hereditary conditions), and an age-appropriate review of patient’s social history (current and past activities). While making your selections, use your cursor to reveal E/M Tooltips that will help you identify the quantifying elements of the PFSH.
The E/M interactive worksheet will automatically calculate the appropriate level of PFSH based upon the user’s selection in the Determining Level of E/M Services section as well as the number of options selected in the PFSH subsection.

Step 5: Determine Examination level (overview) -- required section

There are two examination sections incorporated into the E/M interactive worksheet:
Examination: 1995 E/M Documentation Guidelines
Examination: 1997 E/M Documentation Guidelines
Since each is based upon the specific guidelines referenced, the user’s selection in the Guidelines Selection section will determine which examination sections will be visible during a particular E/M session. If the option Both '95 and '97 Guidelines is selected, both examination sections must be completed for the E/M interactive worksheet to automatically calculate a suggested E/M code.

Step 5a: Determine Examination level based on 1995 guidelines -- (optional)

1995 Examination Section
This examination section will only be visible if either ’95 Guidelines only or Both '95 and '97 Guidelines is selected. An examination based on the 1995 E/M documentation guidelines may involve a single organ system or several. The extent of the examination performed is dependent upon the examiner’s clinical judgment, the patient’s history, and the nature of the presenting problem. Types of examination range from limited examinations of a single body area to general multi-system or complete single organ system examinations.
Your selections in the Body Areas and Organ Systems subsections should be based on those details contained within the patient’s medical record that describe the physician’s examination of the patient. While making your selections, use your cursor to reveal E/M Tooltips that will help you identify the quantifying elements of each body area or system in accordance with 1995 E/M documentation guidelines.
However, since the quality or extent of the physician’s examination is subjective and based upon clinical judgment, the E/M interactive worksheet cannot calculate the 1995 Examination level automatically. The 1995 Examination level is determined by your selection in the Body Area(s) or Organ System(s): Examination Types subsection. However, E/M Tooltips, based on 1995 guidelines, will assist you with determining the appropriate 1995 Examination level:
1995 Examination Level
Note: Once you have made your selection in the Body Area(s) or Organ System(s): Examination Types subsection, the E/M interactive worksheet will use the specified 1995 Examination level in its final calculation of the suggested E/M code based upon 1995 E/M documentation guidelines.

Examination Level -- 1995 E/M Guidelines Reference Table

Examination Levels
Body Area(s) or Organ Systems: ‘95 Guidelines
Problem Focused
A limited examination of the affected body area or organ system.
Expanded Problem Focused
A limited examination of the affected body area/organ system
AND other symptomatic or related organ system(s).
Detailed
An extended examination of the affected body area(s)
AND
other symptomatic or related organ systems.
Comprehensive
A general multi-system examination (including 8 or more organ systems) OR a complete examination of a single organ system

Step 5b: Determine Examination level based on 1997 guidelines -- (optional)

1997 Examination section
This examination section will only be visible if either ’97 Guidelines only or Both '95 and '97 Guidelines is selected. According to the 1997 E/M documentation guidelines, a single organ system examination or a general multi-system examination may be performed by any physician regardless of specialty; however, the documentation requirements differ between the two examination types. The depth and type of the examination performed is dependent upon the examiner’s clinical judgment, the patient’s history, and the nature of the presenting problem.
Your selections in the Body Areas and Organ Systems subsections should be based on those details contained within the patient’s medical record that describe the physician’s examination of the patient. While making your selections, use your cursor to reveal E/M Tooltips that are based on general multi-system examination requirements.
Note: Please refer to the tables contained within the 1997 E/M Documentation Guidelines for specific content criteria for single organ system examinations -- including bullet and shaded/unshaded border specifications -- as well as individual examination elements of the applicable body area or system.
However, since the quality or extent of the physician’s examination is subjective and based upon clinical judgment and type of examination conducted, the E/M interactive worksheet cannot calculate the 1997 Examination level automatically. The 1997 Examination level is determined by your selection in either the Single Organ System: Examination Types subsection or the General Multi-System: Examination Types subsection. However, E/M Tooltips, based on 1997 guidelines, will assist you with determining the appropriate 1997 Examination level:
1997 Examination Level
Once you have made your selection in either the Single Organ System: Examination Types subsection or the General Multi-System: Examination Types subsection, the E/M interactive worksheet will use the specified 1997 Examination level in its final calculation of the suggested E/M code based upon 1997 E/M documentation guidelines.

Examination Level -- 1997 E/M Guidelines Reference Table

Examination Levels
Single Organ System -- ‘97 Guidelines
General Multi-System -- ‘97 Guidelines
Problem Focused
Examination should include performance and documentation of 1-5 bulleted elements.
Examination should include performance and documentation of 1-5 bulleted elements for one or more organ systems or body areas.
Expanded Problem Focused
Examination should include performance and documentation of at least 6 bulleted elements.
Examination should include performance and documentation of at least 6 bulleted elements for one or more organ systems or body areas.
Detailed
Examination should include performance and documentation of at least 12 bulleted elements.
Exception: Eye and psychiatric examinations require only 9 bulleted elements
Examination should include performance and documentation of at least 2 bulleted elements for at least six organ systems or body areas
OR
At least 12
bulleted elements for two or more organ systems/body areas.
Comprehensive
Examination should include performance of ALL bulleted elements.
Note: Documentation of ALL bulleted elements contained within a box with a shaded border and at least 1 element in each box with an unshaded border is expected.
Examination should include performance of ALL bulleted elements for at least 9 organ systems or body areas unless specific directions limit examination content.
Note: Documentation of at least 2 bulleted elements for each area/system is expected.

Step 6: Determine Medical Decision Making level (overview) -- required section

Medical decision making refers to the level of complexity associated with establishing a diagnosis and/or selecting a management option. The level of complexity is measured by the following factors:
Number of Diagnoses or Management Options -- the number of possible diagnoses and/or the number of management options that must be considered by the examiner.
Amount and/or Complexity of Data to Be Reviewed -- the amount and complexity of medical records, diagnostic tests, and/or other information that must be obtained, reviewed, and analyzed by the examiner.
Risk of Significant Complications, Morbidity, and/or Mortality -- the risk of significant complications, morbidity, and/or mortality as well as comorbidities associated with the patient’s presenting problem(s), the diagnostic procedure(s) ordered, and/or the possible management options selected by the examiner.

Decision Making Level: Reference Table -- 2/3 element levels must be met or exceeded

Number of Diagnoses or Management Options
Amount and/or Complexity of Data to Be Reviewed
Risk of Complications, Morbidity, and/or Mortality
Decision Making Level
Minimal
Minimal or None
Minimal
Straightforward
Limited
Limited
Low
Low Complexity
Multiple
Moderate
Moderate
Moderate Complexity
Extensive
Extensive
High
High Complexity
Note: Levels for two out of three Medical Decision Making elements (i.e., Number of Diagnoses or Management Options, Amount and/or Complexity of Data to Be Reviewed, and Risk of Complications, Morbidity, and/or Mortality) must meet or exceed the requirements specified for each level of Medical Decision Making (i.e., Straightforward, Low Complexity, Moderate Complexity, or High Complexity).

Number of Diagnoses or Management Options

The number of possible diagnoses and/or the number of management options that must be considered is based upon the number and types of problems addressed during the patient visit, the complexity associated with establishing a diagnosis, and the management decisions that are made by the physician.
There are four possible levels of Number of Diagnoses or Management Options:
Minimal
Limited
Multiple
Extensive
Your entries in the Number of Diagnoses or Management Options subsection should be based on the documentation contained within the patient’s medical record that describes the patient’s presenting problem(s) including:
Overall description -- (e.g., new, self-limiting, minor)
Diagnosis -- (e.g., new, established)
Current status -- (e.g., stable, improving, inadequately controlled, worsening, resolved)
Diagnostic procedure(s) ordered
Note: A patient may have more than one presenting problem, and different criteria may apply to each. For example, a patient may have an established diagnosis of asthma that is stable; however, they may have recently taken a fall (the reason for the visit), and the physician may decide to order an X-ray to ascertain the severity of the patient’s injury:
Number of Diagnoses or Management Options example
Tip: Users should enter the number of occurrences that match the criteria specified in each option.
Once you have made your entry or entries in the Number of Diagnoses or Management Options subsection, the E/M interactive worksheet will automatically calculate the appropriate element level based on your entries within the subsection and your preferred set of guidelines.

Amount and/or Complexity of Data to Be Reviewed

The amount and complexity of data to be reviewed is based on the types of diagnostic testing ordered or reviewed. A decision to obtain and review old medical records and/or obtain history from sources other than the patient increases the amount and complexity of data to be reviewed.
There are four possible levels of Amount and/or Complexity of Data to Be Reviewed:
Minimal or None
Limited
Moderate
Extensive
Your selections in the Amount and/or Complexity of Data to Be Reviewed subsection should be based on the documentation contained within the patient’s medical record that substantiates:
Diagnostic tests ordered or reviewed
Discussion of test results with the performing/interpreting physician
Reporting of relevant findings from the discussion of the case with another provider
Independent interpretations of a test previously or subsequently interpreted by another physician
Decision by the physician to obtain old medical records or history from someone other than the patient.
Amount and/or Complexity of Data to Be Reviewed
Tip: Users should place a checkmark next to any option that describes services performed and documented during the patient visit.
Once you have made your selection(s) in the Amount and/or Complexity of Data to Be Reviewed subsection, the E/M interactive worksheet will automatically calculate the appropriate element level based on the options selected within the subsection and your preferred set of guidelines.

Risk of Significant Complications, Morbidity, and/or Mortality

The risk of significant complications, morbidity, and/or mortality is based upon the risks associated with the presenting problem(s), the diagnostic procedure(s) ordered, and the management options selected. The assessment of risk of the presenting problem(s) is based on the risk related to the disease process anticipated between the present encounter and the next one. The assessment of risk of selecting diagnostic procedures and management options is based on the risk during and immediately following any procedures or treatment.
There are four possible levels of Risk of Significant Complications, Morbidity, and/or Mortality:
Minimal
Low
Moderate
High
Risk of significant complications, morbidity, and/or mortality
Your selections in the Risk of Significant Complications, Morbidity, and/or Mortality subsection should be based on those details contained within the patient’s medical record that describe the nature of the presenting problem, the diagnostic procedures ordered, and management options selected. Since the determination of risk is complex and not readily quantifiable, use your cursor to reveal E/M Tooltips that will help you quantify the level of risk associated with each quantifying element.
Note: The highest qualifying element will determine the final level of risk.

Risk Table

Level
Presenting Problem
Diagnostic Procedure(s) Ordered
Management Options Selected
Minimal
One self-limited or minor problem ( e.g., cold, insect bite)
Laboratory tests requiring venipuncture
Chest X-rays
EKG/EEG
Urinalysis
Ultrasound
KOH prep
Rest
Gargles
Elastic Bandages
Superficial dressings
Low
Two or more self-limited or minor problems
One stable chronic illness (e.g., well-controlled hypertension, non-insulin dependent diabetes)
One acute uncomplicated illness or injury (e.g., cystitis, sprain
Physiologic tests not under stress (e.g., pulmonary function tests)
Non-cardiovascular imaging studies with contrast (e.g., barium enema)
Superficial needle biopsies
Clinical laboratory tests requiring arterial puncture
Skin biopsies
Over-the-counter drugs
Minor surgery with no identified risk factors
Physical therapy
Occupational therapy
IV fluids without additives
Moderate
One or more chronic illnesses with mild exacerbation, progression, or treatment side effects
Two or more stable chronic illnesses
Undiagnosed new problem with uncertain prognosis
Acute illness with systemic symptoms (e.g., 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
Cardiovascular imaging studies with contrast AND no identified risk factors (e.g., arteriogram, cardiac catheterization)
Obtain fluid from body cavity (e.g., lumbar puncture, thoracentesis, culdocentesis)
Minor surgery with identified risk factors
Elective major surgery (open, percutaneous, or endoscopic) with no identified risk factors
Prescription drug management
Therapeutic nuclear medicine
IV fluids with additives
Closed treatment of fracture or dislocation without manipulation
High
One or more chronic illnesses with severe exacerbation, progression, or treatment side effects
Acute or chronic illnesses or injuries that may pose a threat to life or bodily function (e.g., pulmonary embolus, severe respiratory distress, psychiatric illness with potential threat to self or others)
An abrupt change in neurologic status (e.g., seizure, TIA, sensory loss)
Cardiovascular imaging studies with contrast AND with identified risk factors
Cardiac electrophysiological tests
Diagnostic Endoscopies with identified risk factors
Discography
Elective major surgery (open, percutaneous, or endoscopic) with identified risk factors
Emergency major surgery (open, percutaneous, or endoscopic)
Parenteral controlled substances
Drug therapy requiring intensive monitoring for toxicity
Decision not to resuscitate or to de-escalate care because of poor prognosis
Once you have made your selections in the Risk of Significant Complications, Morbidity, and/or Mortality subsection, the E/M interactive worksheet will automatically calculate the appropriate Medical Decision Making level based on your entries in all three subsections and preferred set of guidelines.

Step 7: Calculation of suggested E/M code

Once you have made all of your selections, the E/M interactive worksheet will automatically calculate a suggested E/M code based upon your entries and preferred set of guidelines:
Suggested E/M code
Tip: If the E/M interactive worksheet does not calculate a suggested E/M code, please check to ensure that you have completed all required sections of the worksheet.
After you have completed your E/M session, you have the following options:
Use the Clear Worksheet button to clear your entries and begin a new session.
Use the Print Worksheet button to print a copy of your completed worksheet to include within the medical record.
Tip: You may use your copy of Adobe Acrobat to print an electronic copy of your completed worksheet.
First Coast Service Options (First Coast) strives to ensure that the information available on our provider website is accurate, detailed, and current. Therefore, this is a dynamic site and its content changes daily. It is best to access the site to ensure you have the most current information rather than printing articles or forms that may become obsolete without notice.