Evaluation & Management Review Checklist and Scoresheet Form

N/A - history components do not apply to this patient

History of Present Illness (HPI)

Location	Duration	Modifying Factors
Quality	Timing	Associated Signs & Symptoms
Severity	Context	Status of 3 or more chronic/inactive conditions

Location	Duration	Modifying Factors
Quality	Timing	Associated Signs & Symptoms
Severity	Context	Status of 3 or more chronic/inactive conditions

Comments:

Review of Systems (ROS):

None

Comments:

History: Past Family Social

None

Comments:

N/A - physical examination does not apply to this patient

Body Areas: Limited Examination Extended Examination

Comments:

Systems: Limited Examination Extended Examination

Complete Examination of a Single Organ System
Specify Organ System:

Comments:

N/A - physical examination does not apply to this patient

Systems: Select the affected system and identify the examination type from the Doc Guideline for Evaluation & Evaluation & Management Services (PDF 1MB)

Type of Exam:

Systems/Specialty:

Examination Type:

N/A - medical decision making does not apply to this patient

Number of Diagnoses or Management Options:

Problem(s)/Status	Number	Points
Self/limited or minor; stable, improved or worsening [Max = 2]		1
Established diagnosis/problem; Stable, improved		1
Established diagnosis/problem; worsening		2
New problem; no additional work-up planned [Max = 1]		3
New problem, additional work-up planned/consultation		4
	Total Score = ?

Comments:

Amount and Complexity of Data Reviewed

Reviewed Data		Points
Review and/or order clinical lab tests (e.g. CPT 8XXXX series)		1
Review and/or order radiology tests (e.g. CPT 7XXXX series)		1
Review and/or order medicine tests (e.g. CPT 9XXXX series)		1
Discuss test results with performing/interpreting physician		1
Independent review of image, tracing, or specimen		2
Decision to obtain old records and/or decision to obtain history from others		1
Review and summarize old records and/or history obtained from others		2
Total Points = ?

Comments:

Assessment of Risk (Examples are NOT all inclusive):

--Hover your mouse over the question marks for more information

Presenting Problem	Diagnostic Procedure	Management Options
Risk Level: Minimal
One self-limited or minor problem ? Other:	Laboratory tests requiring venipunture CXR or X-ray Ultrasound EKG/EEG KOH Prep UA Other:	Rest Gargles Elastic bandages Superficial dressings Other:
Risk Level: Low
Two or more self-limited or minor problems One stable chronic illness - well controlled ? Acute uncomplicated illness/ injury ? Other:	Physiological tests not under stress ? Non-cardiovascular imaging studies w/ contrast ? Superficial needle biopsies Clinical laboratory tests requiring arterial puncture ? Skin biopsies Other:	Over-the-counter drugs Minor surgery with no identified risk factors IV fluids without additives Physical Therapy Occupational Therapy Other:
Risk Level: Moderate
One or more chronic illnesses with mild exacerbation, progression or side effects of treatment Two or more stable chronic illnesses Undiagnosed new problem with uncertain prognosis ? Acute illness with systemic symptoms ? Acute complicated injury ? Other:	Physiologic test under stress ? Diagnostic endoscopies w/ no identified risk factors Deep needle/incisional biopsy Cardiovascular imaging studies with contrast and no identified risk factors ? Obtain fluids from a body cavity ? Other:	Minor surgery with identified risk factors Elective major surgery with no identified risk factors ? IV fluids with additives Closed treatment of fracture or dislocation without manipulation Therapeutic nuclear medicine Prescription drug management Other:
Risk Level: High
One or more chronic illnesses with severe exacerbation, progression or side effects of treatment Acute or chronic illnesses or injuries that pose a threat to life or bodily function ? Abrupt change in neurologic status ? Other:	Cardiovascular imaging studies with contrast and identified risk factors Cardiac electro-physiological tests ? Diagnostic endoscopies with identified risk factors Discography Other:	Elective major surgery with identified risk factors ? Decision for DNR, or not to continue care due to poor prognosis Parenteral controlled substances Drug therapy requiring intensive monitoring for toxicity Emergency major surgery Other:

Presenting Problem

Diagnostic Procedure

Management Options

Risk Level: Minimal

One self-limited or minor
problem ?

Other:

Laboratory tests requiring
venipunture

CXR or X-ray

Ultrasound EKG/EEG

KOH Prep UA

Other:

Rest Gargles

Elastic bandages

Superficial dressings

Other:

Risk Level: Low

Two or more self-limited or
minor problems

One stable chronic illness -
well controlled ?

Acute uncomplicated illness/
injury ?

Other:

Physiological tests not under stress ?

Non-cardiovascular imaging
studies w/ contrast ?

Superficial needle biopsies

Clinical laboratory tests requiring arterial puncture ?

Skin biopsies

Other:

Over-the-counter drugs

Minor surgery with no
identified risk factors

IV fluids without additives

Physical Therapy

Occupational Therapy

Other:

Risk Level: Moderate

One or more chronic illnesses with mild exacerbation, progression or side effects of
treatment

Two or more stable chronic
illnesses

Undiagnosed new problem
with uncertain prognosis ?

Acute illness with systemic
symptoms ?

Acute complicated injury ?

Other:

Physiologic test under stress ?

Diagnostic endoscopies w/ no identified risk factors

Deep needle/incisional biopsy

Cardiovascular imaging studies with contrast and no identified risk factors ?

Obtain fluids from a body cavity ?

Other:

Minor surgery with identified
risk factors

Elective major surgery with
no identified risk factors ?

IV fluids with additives

Closed treatment of fracture
or dislocation without
manipulation

Therapeutic nuclear medicine

Prescription drug management

Other:

Risk Level: High

One or more chronic illnesses with severe exacerbation, progression or side effects of treatment

Acute or chronic illnesses or
injuries that pose a threat to
life or bodily function ?

Abrupt change in neurologic
status ?

Other:

Cardiovascular imaging studies with contrast and identified risk factors

Cardiac electro-physiological tests ?

Diagnostic endoscopies with
identified risk factors

Discography

Other:

Elective major surgery with
identified risk factors ?

Decision for DNR, or not to
continue care due to poor
prognosis

Parenteral controlled
substances

Drug therapy requiring
intensive monitoring for
toxicity

Emergency major surgery

Other:

If the physician documents total time and indicates that counseling and/or coordination of care dominates (more than 50%) the face-to-face physician/patient encounter or the floor time (in case of inpatient services), time is the key or controlling factor in selecting the level of service.

Does documentation reveal total time? Yes No
If yes, enter time:

Does documentation describe in sufficient detail the content of counseling and/or coordination of care? Yes No
If yes, enter time:

Does documentation reveal that more than half of the time spent was counseling and/or coordination of care? Yes No
If yes, enter time:

If all answers are "Yes" select the level of service based on time

CPT Code Selected:

	Office or Other Outpatient Visit
	Office Consultation
	Inpatient Consultation
	Initial Hospital Care
	Initial Observation Care
	Observation or Inpatient Hospital Care Including Admission and Discharge Services
	Initial Nursing Facility Care
	Emergency Department Services or Emergency Department Visit
	Domiciliary/Rest Home Visit
	Home Services or Home Visit
	Other Nursing Facility Services

*Beneficiary's First Initial:
*Beneficiary's Last Name:
Diagnosis:
*DOS:	(e.g use date picker or format mm/dd/yyyy)
Chief Complaint:

Constitutional Symptoms (e.g., fever, weight loss)	Respiratory	Integumentary(skin and/or breast)	Hematologic/Lymphatic
Eyes	Gastrointestinal	Neurological	Allergic/Immunologic
Ears, Nose, Mouth, Throat	Genitourinary	Psychiatric	All Other Neg
Cardiovascular	Musculoskeletal	Endocrine

Head, incl Face	Abdomen	Right Upper Extremity
Neck	Back/Spine	Left Upper Extremity
Chest/Breasts/Axillae	Genitalia/Groin/Buttocks	Right Lower Extremity
		Left Lower Extremity

Constitutional	Cardiovascular	Genitourinary	Neurologic
Eyes	Respiratory	Musculoskeletal	Psychiatric
Ears, nose, mouth, and throat	Gastrointestinal	Skin	Hematologic/ lymphatic/ immunologic