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Railroad Medicare
Instructions for E/M Review Checklist and Score Sheet Tool for New Patients

To complete the Evaluation and Management Review Checklist and Score Sheet Tool for New Patients (Three of three Components), view www.palmettogba.com/eandmnewpt.

Basic Patient Information

  • E/M Service: Select the type/place of service provided. For example, if the type/place of service provided is an office visit, click on 'Office Visit' radio button.
  • Examination Guidelines:  1995/1997 -  Choose the appropriate filing guideline year. If filing using the 1995 guidelines, click on the 1995 radio button. If filing using the 1997 guidelines, click on the 1997 radio button.
  • *Beneficiary’s First Initial: Enter the initial of the beneficiary’s first name
  • *Beneficiary’s Last Name: Enter the beneficiary’s last name
  • Diagnosis: Enter the beneficiary’s diagnosis
  • *DOS: Enter the date of service or click on the calendar to choose the date of service
  • Chief Complaint: Enter the beneficiary’s chief complaint or reason for the encounter
    • Note: *indicates a required field

History Components
Note:
If billing for an established patient office visit procedure code 99211, click in the box beside 'N/A - history components do not apply to this patient.' Proceed to the Physical Examination section.

  1. History of Present Illness (HPI): Click on the element(s) describing the development of the patient’s present illness from the first sign and/or symptom or from the previous encounter to the present. At least one element in the History of Present Illness must be selected.
    • Note: If 'Status of 3 chronic/inactive diseases' is selected and you receive the error message 'When selecting Status of 3 chronic/inactive diseases; you must file as year 1997, or deselect Status of 3 chronic/inactive diseased,' you have an option of deselecting the status of 3 chronic/inactive diseases and continue filing using the 1995 guideline year or file the claim using the 1997 guideline year. If 1997 guideline year is selected, return to the Basic Patient Information section and click on 1997.
  2. Review of Systems (ROS): Click on the system(s) for which signs and/or symptoms which the patient may be experiencing or has experienced have been identified by a series of questions.
    • If review of systems is not obtained, click 'None' for N/A
    • If 'All Other Neg' is selected, at least one systems assessed to be positive must be selected
    • If the beneficiary is unable to provide information, the following documentation must be present in the medical record:
      • Reason why the patient is unable to provide the history
      • Indicate the source(s) used to obtain the information
      • Information obtained from these sources
    • Note: The score would be based on the information obtained from the alternate source(s) to complete the Review of System
  3. History: Past, Family, Social: Click on the area(s) of history reviewed. If Past, Family or Social history is not obtained, click 'None' for NA.
  4. Click on 'Update Type' to determine the History Type

History Components
Note: If billing for an established patient office visit procedure code 99211, click in the box beside 'N/A - history components do not apply to this patient.' Proceed to the Physical Examination section.

  • History of Present Illness (HPI): Click on the element(s) describing the development of the patient’s present illness from the first sign and/or symptom or from the previous encounter to the present.

OR

If the documentation supports the “status of 3 or more chronic/inactive conditions,” click on the “status of 3 or more chronic/inactive conditions.”

  • Review of Systems (ROS): Click on the system(s) for which signs and/or symptoms which the patient may be experiencing or has experienced have been identified by a series of questions.
    • If review of systems is not obtained, click 'None' for N/A
    • If 'All Other Neg' is selected, at least one systems assessed to be positive must be selected
    • If the beneficiary is unable to provide information, the following documentation must be present in the medical record:
      • Reason why the patient is unable to provide the history
      • Indicate the source(s) used to obtain the information
      • Information obtained from these sources
    • Note: The score would be based on the information obtained from the alternate source(s) to complete the Review of System
  • History: Past, Family, Social: Click on the area(s) of history reviewed. If Past, Family or Social history is not obtained, click 'None' for NA.
  • Click on 'Update Type' to determine the History Type

Physical Examination
1995 Guidelines:

  • Body Areas- Limited Examination or Extended Examination: Click on the type of physical examination performed whether limited or extended. Limited examinations will yield problem-focused or expanded problem-focused outcomes. Extended examination will yield a detailed or comprehensive outcome. Click on the body area(s) examined.
  • Systems- Limited Examination or Extended Examination: Click on the type of physical examination performed whether limited or extended. Limited examinations will yield problem-focused or expanded problem-focused outcomes. Extended examination will yield a detailed or comprehensive outcome. Click on the body system(s) examined.
  • Using the 1995 guidelines, if the 'Complete Examination of a Single Organ System' is selected, the organ system assessed must be specified in the space provided
  • Click on 'Update Type' to determine the Physical Examination Type

1997 Guidelines:

  • 'Systems': In the drop-down box, click on the type of examination performed whether General Multi-System Examinations or Single Organ System Examination. In the drop-down box, click on the system assessed and the level of examination as indicated in the Content and Documentation Requirements.

Medical Decision Making

  • Number of Diagnoses or Management Options: In the Number field, indicate the number and types of problems addressed during the encounter. Complete each of the Number fields as applicable.
  • Amount and Complexity of Data Reviewed: Click on the reviewed data as applicable
  • Assessment of Risk: Click on the level of risk in any one category (presenting problem(s), diagnostic procedure(s), or management option(s).) If 'Other' is selected, key the information in the space provided.
  • Click on 'Update Type' to determine the Medical Decision Making Type

Counseling and/or Coordination of Care

  • If all answers are 'Yes' to the questions, you have an option of selecting the level of service based on time. Refer to Current Procedural Terminology (CPT) book available from the American Medical Association at 800-621-8335 or http://www.amapress.org/ for appropriate CPT code.

CPT Code Selected: Key the appropriate CPT code based on time as indicated in the CPT manual.

The CPT CODE Selection is: Click on 'Update' to determine the appropriate CPT code.

Note: The provider has an option of selecting the CPT code to bill based on time as indicated in the Counseling and/or Coordination of Care or based on the CPT code generated from the History, Physical Examination and Medical Decision Making.

Comments: Provide any additional comments as appropriate

Print: To print the completed tool, click on the Print button

Note: If you have Adobe Professional, you have the option to save the completed tool as a PDF document. To do so, choose 'Adobe PDF' in the printer drop-down options, click on print and save the document for future reference.

Reset Form: Click on the Reset Form to clear the form and enter new data  

Reminders:

Other Resources:

Note: The tool will continue to be updated as new scenarios are encountered. If a new scenario is entered into the tool, the application will automatically notify the system administrator. The user will get a message saying 'Sorry - Error with Form - an email alert has been sent to the Administrator to correct.' The system administrator will revise the form to accommodate the scenario encountered.


 

last updated on 09/10/2013
ver 1.0.51