|
1995 Guidelines
| |
NEW
99204Must have all 3
components: Hx, Ex, MDM
Faculty to be present during
critical portions
|
ESTABLISHED
99214Must have 2 out of
3 components: Hx, Ex, MDM
FAculty to be present during
critical portions
|
|
History |
Comprehensive =
• Chief Complaint
• Extended HPI (4+)
• Complete ROS (10 systems)
• Complete PHM, PFH, SH (at least one
element from all hx areas 1 each) |
Detailed =
• Chief Complaint
• Extended HPI (4+)
• Extended ROS (2-9 systems)
• Pertinent PHM, PFH, SH (1 of the hx
areas) |
|
Exam |
Comprehensive =
Multisystem =
• At least 8 or more orgam systems |
Detailed =
• Up to 7 organ systems body areas |
|
Medical Decision Making
|
Moderate =
• Multiple number of diagnoses or
management options considered
• Moderate amount or complexity of data
reviewed
• Moderate risk complic/ morbidity/ mort
• Problems should be moderate to high
severity. |
Moderate =
• Multiple number of diagnoses or
management options considered
• Moderate amount or complexity of data
reviewed
• Moderate risk complic/ morbidity/ mort
• Problems should be moderate to high
severity. |
|
Time |
Approximately 45 minutes |
Approximately 25 minutes |
Additional Resources from CMS:
http://www.cms.hhs.gov/medlearn/Teaching-Physician-Brochure-9-29-04.pdf
http://www.cms.hhs.gov/medlearn/mrnp-guide.pdf
Faculty Documentation:
Any of the below would work, it doesn't
matter what the level is as long as the resident
has captured all the required elements for a
specific level, i.e., appropriate level of
history, exam and medical decision making.
Initial Visit: "I saw and evaluated the
patient. I reviewed the resident's note and
agree, except that picture is more consistent
with pericarditis than myocardial ischemia. Will
begin NSAIDs."
Initial or Follow-up Visit: "I saw and
evaluated the patient. Discussed with resident
and agree with resident's findings and plan as
documented in the resident's note."
Follow-up Visit: "See resident's note for
details. I saw and evaluated the patient and
agree with the resident's finding and plans as
written." Or "I saw and evaluated the patient.
Agree with resident's note but lower extremities
are weaker, now 3/5; MRI of L/S Spine today."
Unacceptable Documentation:
"Agree with above", "Reviewed and Agree",
"Discussed with the resident, agree", "Seen and
agree", "Patient seen and evaluated".
Karen Boland, RN, CPC
Manager Reimbursement DOM
Univ. Alabama Health Svcs. Foundation
205-801-7943
kboland@uabmc.edu |
