Assignment Prompt & Instructions
– 2 years ago
**files (3)**
– ## Note1.docx
– ## EvaluationandManagementEMScoreSheet8985-2-1.pdf
– PediatricSOAPTemplateandRubric-1.docx
**## Note1.docx**
**Directions:** Read over the SOAP note and formulate a primary diagnosis. Based on the diagnosis complete the SOAP note with the details that would be expected for the diagnosis. Use UptoDate and/or Dyna MedPlus to find out what is expected from the history and physical, diagnostic workup and management for the diagnosis. Include other peer review resources and and journal articles to support the development of your SOAP note. Complete and attach the evaluation & management score sheet to show how you coded the note for billing in each section.
· Upload a copy of your completed SOAP note.
· Upload a copy of the evaluation & management score sheet.
**Case Study:** A 3-year-old girl is brought to your office by her mother because she has a fever and complains that her right ear hurts. She has no significant medical history. The child is not pleased to be in the PCP's office and has been crying. Her mother explains that she developed a “cold” about 3 days ago with sniffles. Her temperature is 37.8°C (100°F). Physical exam was completed with some difficulty because of the child's irritability. The only abnormalities are slight redness of the throat, a nose full of thick green mucus, and injected tympanic membranes. She denies nausea, vomiting, diarrhea, headache, or change in urine output.
**## EvaluationandManagementEMScoreSheet8985-2-1.pdf**
E/M Documentation Auditor’s Instructions
1. History
Refer to data section (table below) in order to quantify. After referring to data, circle the entry farthest to the RIGHT in the table, which
best describes the HPI, ROS and PFSH. If one column contains three circles, draw a line down that column to the bottom row to
identify the type of history. If no column contains three circles, the column containing a circle farthest to the LEFT, identifies the type
of history.
After completing this table which classifies the history, circle the type of history within the appropriate grid in Section 5.
HPI: Status of chronic conditions:
q 1 condition q 2 conditions q 3 conditions
q
Status of
1-2 chronic
Status of 3
chronic
conditions conditionsOR
HPI (history of present illness) elements:
q Location q Severity q Timing q Modifying factors
q Quality q Duration q Context q Associated signs and symptoms
q
Brief
(1-3)
Extended
(4 or more)
ROS (review of systems):
q Constitutional q Ears,nose, q GI q Integumentaryq Endo
(wt loss, etc) mouth, throat q GU (skin, breast) q Hem/lymph
q Eyes q Card/vasc q Musculo q Neuro q All/immuno
q Resp q Psych q All others negative
q
None
q
Pertinent to
problem
(1 system)
q
Extended
(2-9 systems)
*Complete
PFSH (past medical, family, social history) areas:
q Past history ( the patient's past experiences with illnesses, operation, injuries and treatments)
q Family history (a review of medical events in the patient's family, including diseases which may be
hereditary or place the patient at risk)
q Social history (an age appropriate review of past and current activities)
plete ROS: 10 or more systems or the pertinent positives and/or negatives of
q
None
q
Pertinent
(1 history area)
e**Complet
y(2 or 3 histor
areas)
PROBLEM
FOCUSED
EXP.PROB.
FOCUSED DETAILED -COMPRE
HENSIVE
q
T
O
R
Y
I
S
H
*Com
some systems with a statement “all others negative”.
**Complete PFSH: 2 history areas: a) Established Patients – Office (Outpatient) Care; b) Emergency Department.
3 history areas: a) New Patients – Office (Outpatient) Care, Domiciliary Care, Home Care; b) Initial Hospital Care;
c) Initial Hospital Observation; d) Initial Nursing Facility Care.
NOTE:For certain categories of E/M services that include only an interval history, it is not necessary to record
information about the PFSH. Please refer to procedure code descriptions.
2. Examination
Refer to data section (table below) in order to quantify. After referring to data, identify the type of examination.
Circle the type of examination within the appropriate grid in Section 5.
Limited to affected body area or organ system (one body area or system related to problem) PROBLEM FOCUSED EXAM
Affected body area or organ system and other symptomatic or related organ system(s)
(additional systems up to total of 7)
EXPANDED PROBLEM
FOCUSED EXAM
Extended exam of affected area(s) and other symptomatic or related organ system(s)
(additional systems up to total of 7 or more depth than above) DETAILED EXAM
General multi-system exam (8 or more systems) or complete exam of a single organ system
(complete single exam not defined in these instructions) COMPREHENSIVE EXAM
A
M
E
X
Body areas:
q Head, including face q Chest, including breasts and axillae
q Back, including spine qGenitalia, groin, buttocks
Organ systems:
q
q
Abdomen q Neck
Each extremity
q q q
1 body
area or
system
Up to 7
systems
Up to 7 8 or more
systems systems
q Constitutional q Ears,nose, q Resp q Musculo q Psych
) (e.g., vitals, gen app mouth, throat q GI q Skin
q Eyes q Cardiovascular q GU q Neuro
q Hem/lymph/imm
PROBLEM
FOCUSED
EXP.PROB.
FOCUSED DETAILED COMPRE-
HENSIVE
q
– 1 –
q
q
q
3. Medical Decision Making
Number of Diagnoses or Treatment Options
Identify each problem or treatment option mentioned in the record.
Enter the number in each of the categories in Column B in the table
below. (There are maximum number in two categories.)
Number of Diagnoses or Treatment Options
A B X C = D
Problem(s) Status Number Points Result
Self-limited or minor
(stable, improved or worsening) Max = 2 1
Est. problem (to examiner); stable, improved 1
Est. problem (to examiner); worsening 2
New problem (to examiner); no additional
workup planned
Max = 1
3
New prob. (to examiner); add. workup planned 4
TOTAL
Multiply the number in columns B & C and put the product in column D.
Enter a total for column D.
Bring total to line A in Final Result for Complexity (table below)
Amount and/or Complexity of Data Reviewed
For each category of reviewed data identified, circle the number in the points
column. Total the points.
Amount and/or Complexity of Data Reviewed
Reviewed Data Points
1
1
1
1
1
2
2
Review and/or order of clinical lab tests
Review and/or order of tests in the radiology section of CPT
Review and/or order of tests in the medicine section of CPT
Discussion of test results with performing physician
Decision to obtain old records and/or obtain history from
someone other than patient
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
Independent visualization of image, tracing or specimen itself
(not simply review of report)
TOTAL
Bring total to line C in Final Result for Complexity (table below)
Use the risk table below as a guide to assign risk factors. It is understood that the table below does not
contain all specific instances of medical care; the table is intended to be used as a guide. Circle the
most appropriate factor(s) in each category. The overall measure of risk is the highest level circled.
Enter the level of risk identified in Final Result for Complexity (table below).Risk of Complications and/or Morbidity or Mortality
Level of
Risk
Presenting Problem(s) Diagnostic Procedure(s)
Ordered
Management Options
Selected
Minimal
• 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
Low
• Two or more self-limited or minor problems
• One stable chronic illness, e.g., well controlled
hypertension or 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.,pulmonary
function tests
• Non-cardiovascular imaging studies with contrast,
e.g., barium enema
• Superficial needle biopsies
• Clincal 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 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
• Cardiovascular imaging studies with contrast and no
identified risk factors, e.g., arteriogram cardiac cath
• 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 addititives
• Closed treatment of fracture or dislocation without
manipulation
High
• One or more chronic illnesses with severe exacerbation,
progression, or side effects of treatment
• 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
• An abrupt change in neurologic status, e.g., seizure, TIA,
weakness or sensory loss
• Cardiovascular imaging studies with contrast 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
Final Result for Complexity
Draw a line down any column with 2 or 3 circles to identify the type of decision making in
that column. Otherwise, draw a line down the column with the 2nd circle from the left.
After completing this table, which classifies complexity, circle the type of decision
making within the appropriate grid in Section 5.
Final Result for Complexity
A Number diagnoses or
treatment options
≤ 1
Minimal
2
Limited
3
Multiple
≥ 4
Extensive
B Highest Risk Minimal Low Moderate High
C Amount and complexity
of data
≤ 1
Minimal
or low
2
Limited
3
Multiple
≥ 4
Extensive
Type of decision making STRAIGHT-
FORWARD
LOW
COMPLEX.
MODERATE
COMPLEX.
HIGH
COMPLEX.
4. Time
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.
Face-to-face in outpatient setting
Does documentation reveal total time? Time: Unit/floor in inpatient setting Yes No
Does documentation describe the content of counseling or coordinating care? Yes No
Does documentation reveal that more than half of the time was counseling or
coordinating care? Yes No
If all answers are "yes", select level based on time.
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– Novitas Solutions Documentation Worksheet
– History Section
– Examination Section
– Medical Decision Making Section
– Time Section
– Level of Service Grids
001. 1:
002. 1_2:
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**PediatricSOAPTemplateandRubric-1.docx**
This file is too large to display. [View in new window](https://www.sweetstudy.com/files/pediatricsoaptemplateandrubric-1-docx)
**PediatricSOAPTemplateandRubric-1.docx**
This file is too large to display. [View in new window](https://www.sweetstudy.com/files/pediatricsoaptemplateandrubric-1-docx)
**## Note1.docx**
**Directions:** Read over the SOAP note and formulate a primary diagnosis. Based on the diagnosis complete the SOAP note with the details that would be expected for the diagnosis. Use UptoDate and/or Dyna MedPlus to find out what is expected from the history and physical, diagnostic workup and management for the diagnosis. Include other peer review resources and and journal articles to support the development of your SOAP note. Complete and attach the evaluation & management score sheet to show how you coded the note for billing in each section.
· Upload a copy of your completed SOAP note.
· Upload a copy of the evaluation & management score sheet.
**Case Study:** A 3-year-old girl is brought to your office by her mother because she has a fever and complains that her right ear hurts. She has no significant medical history. The child is not pleased to be in the PCP's office and has been crying. Her mother explains that she developed a “cold” about 3 days ago with sniffles. Her temperature is 37.8°C (100°F). Physical exam was completed with some difficulty because of the child's irritability. The only abnormalities are slight redness of the throat, a nose full of thick green mucus, and injected tympanic membranes. She denies nausea, vomiting, diarrhea, headache, or change in urine output.
**## EvaluationandManagementEMScoreSheet8985-2-1.pdf**
E/M Documentation Auditor’s Instructions
1. History
Refer to data section (table below) in order to quantify. After referring to data, circle the entry farthest to the RIGHT in the table, which
best describes the HPI, ROS and PFSH. If one column contains three circles, draw a line down that column to the bottom row to
identify the type of history. If no column contains three circles, the column containing a circle farthest to the LEFT, identifies the type
of history.
After completing this table which classifies the history, circle the type of history within the appropriate grid in Section 5.
HPI: Status of chronic conditions:
q 1 condition q 2 conditions q 3 conditions
q
Status of
1-2 chronic
Status of 3
chronic
conditions conditionsOR
HPI (history of present illness) elements:
q Location q Severity q Timing q Modifying factors
q Quality q Duration q Context q Associated signs and symptoms
q
Brief
(1-3)
Extended
(4 or more)
ROS (review of systems):
q Constitutional q Ears,nose, q GI q Integumentaryq Endo
(wt loss, etc) mouth, throat q GU (skin, breast) q Hem/lymph
q Eyes q Card/vasc q Musculo q Neuro q All/immuno
q Resp q Psych q All others negative
q
None
q
Pertinent to
problem
(1 system)
q
Extended
(2-9 systems)
*Complete
PFSH (past medical, family, social history) areas:
q Past history ( the patient's past experiences with illnesses, operation, injuries and treatments)
q Family history (a review of medical events in the patient's family, including diseases which may be
hereditary or place the patient at risk)
q Social history (an age appropriate review of past and current activities)
plete ROS: 10 or more systems or the pertinent positives and/or negatives of
q
None
q
Pertinent
(1 history area)
e**Complet
y(2 or 3 histor
areas)
PROBLEM
FOCUSED
EXP.PROB.
FOCUSED DETAILED -COMPRE
HENSIVE
q
T
O
R
Y
I
S
H
*Com
some systems with a statement “all others negative”.
**Complete PFSH: 2 history areas: a) Established Patients – Office (Outpatient) Care; b) Emergency Department.
3 history areas: a) New Patients – Office (Outpatient) Care, Domiciliary Care, Home Care; b) Initial Hospital Care;
c) Initial Hospital Observation; d) Initial Nursing Facility Care.
NOTE:For certain categories of E/M services that include only an interval history, it is not necessary to record
information about the PFSH. Please refer to procedure code descriptions.
2. Examination
Refer to data section (table below) in order to quantify. After referring to data, identify the type of examination.
Circle the type of examination within the appropriate grid in Section 5.
Limited to affected body area or organ system (one body area or system related to problem) PROBLEM FOCUSED EXAM
Affected body area or organ system and other symptomatic or related organ system(s)
(additional systems up to total of 7)
EXPANDED PROBLEM
FOCUSED EXAM
Extended exam of affected area(s) and other symptomatic or related organ system(s)
(additional systems up to total of 7 or more depth than above) DETAILED EXAM
General multi-system exam (8 or more systems) or complete exam of a single organ system
(complete single exam not defined in these instructions) COMPREHENSIVE EXAM
A
M
E
X
Body areas:
q Head, including face q Chest, including breasts and axillae
q Back, including spine qGenitalia, groin, buttocks
Organ systems:
q
q
Abdomen q Neck
Each extremity
q q q
1 body
area or
system
Up to 7
systems
Up to 7 8 or more
systems systems
q Constitutional q Ears,nose, q Resp q Musculo q Psych
) (e.g., vitals, gen app mouth, throat q GI q Skin
q Eyes q Cardiovascular q GU q Neuro
q Hem/lymph/imm
PROBLEM
FOCUSED
EXP.PROB.
FOCUSED DETAILED COMPRE-
HENSIVE
q
– 1 –
q
q
q
3. Medical Decision Making
Number of Diagnoses or Treatment Options
Identify each problem or treatment option mentioned in the record.
Enter the number in each of the categories in Column B in the table
below. (There are maximum number in two categories.)
Number of Diagnoses or Treatment Options
A B X C = D
Problem(s) Status Number Points Result
Self-limited or minor
(stable, improved or worsening) Max = 2 1
Est. problem (to examiner); stable, improved 1
Est. problem (to examiner); worsening 2
New problem (to examiner); no additional
workup planned
Max = 1
3
New prob. (to examiner); add. workup planned 4
TOTAL
Multiply the number in columns B & C and put the product in column D.
Enter a total for column D.
Bring total to line A in Final Result for Complexity (table below)
Amount and/or Complexity of Data Reviewed
For each category of reviewed data identified, circle the number in the points
column. Total the points.
Amount and/or Complexity of Data Reviewed
Reviewed Data Points
1
1
1
1
1
2
2
Review and/or order of clinical lab tests
Review and/or order of tests in the radiology section of CPT
Review and/or order of tests in the medicine section of CPT
Discussion of test results with performing physician
Decision to obtain old records and/or obtain history from
someone other than patient
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
Independent visualization of image, tracing or specimen itself
(not simply review of report)
TOTAL
Bring total to line C in Final Result for Complexity (table below)
Use the risk table below as a guide to assign risk factors. It is understood that the table below does not
contain all specific instances of medical care; the table is intended to be used as a guide. Circle the
most appropriate factor(s) in each category. The overall measure of risk is the highest level circled.
Enter the level of risk identified in Final Result for Complexity (table below).Risk of Complications and/or Morbidity or Mortality
Level of
Risk
Presenting Problem(s) Diagnostic Procedure(s)
Ordered
Management Options
Selected
Minimal
• 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
Low
• Two or more self-limited or minor problems
• One stable chronic illness, e.g., well controlled
hypertension or 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.,pulmonary
function tests
• Non-cardiovascular imaging studies with contrast,
e.g., barium enema
• Superficial needle biopsies
• Clincal 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 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
• Cardiovascular imaging studies with contrast and no
identified risk factors, e.g., arteriogram cardiac cath
• 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 addititives
• Closed treatment of fracture or dislocation without
manipulation
High
• One or more chronic illnesses with severe exacerbation,
progression, or side effects of treatment
• 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
• An abrupt change in neurologic status, e.g., seizure, TIA,
weakness or sensory loss
• Cardiovascular imaging studies with contrast 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
Final Result for Complexity
Draw a line down any column with 2 or 3 circles to identify the type of decision making in
that column. Otherwise, draw a line down the column with the 2nd circle from the left.
After completing this table, which classifies complexity, circle the type of decision
making within the appropriate grid in Section 5.
Final Result for Complexity
A Number diagnoses or
treatment options
≤ 1
Minimal
2
Limited
3
Multiple
≥ 4
Extensive
B Highest Risk Minimal Low Moderate High
C Amount and complexity
of data
≤ 1
Minimal
or low
2
Limited
3
Multiple
≥ 4
Extensive
Type of decision making STRAIGHT-
FORWARD
LOW
COMPLEX.
MODERATE
COMPLEX.
HIGH
COMPLEX.
4. Time
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.
Face-to-face in outpatient setting
Does documentation reveal total time? Time: Unit/floor in inpatient setting Yes No
Does documentation describe the content of counseling or coordinating care? Yes No
Does documentation reveal that more than half of the time was counseling or
coordinating care? Yes No
If all answers are "yes", select level based on time.
– 2 –
M
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D
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C
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M
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– Novitas Solutions Documentation Worksheet
– History Section
– Examination Section
– Medical Decision Making Section
– Time Section
– Level of Service Grids
001. 1:
002. 1_2:
003. 2:
004. 3:
005. 4:
006. Check Box1: Off
007. Check Box2: Off
008. Check Box3: Off
009. Check Box4: Off
010. Check Box5: Off
011. Check Box6: Off
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015. Check Box10: Off
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029. Check Box27: Off
030. Check Box28: Off
031. Text29:
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**PediatricSOAPTemplateandRubric-1.docx**
This file is too large to display. [View in new window](https://www.sweetstudy.com/files/pediatricsoaptemplateandrubric-1-docx)
**## Note1.docx**
**Directions:** Read over the SOAP note and formulate a primary diagnosis. Based on the diagnosis complete the SOAP note with the details that would be expected for the diagnosis. Use UptoDate and/or Dyna MedPlus to find out what is expected from the history and physical, diagnostic workup and management for the diagnosis. Include other peer review resources and and journal articles to support the development of your SOAP note. Complete and attach the evaluation & management score sheet to show how you coded the note for billing in each section.
· Upload a copy of your completed SOAP note.
· Upload a copy of the evaluation & management score sheet.
**Case Study:** A 3-year-old girl is brought to your office by her mother because she has a fever and complains that her right ear hurts. She has no significant medical history. The child is not pleased to be in the PCP's office and has been crying. Her mother explains that she developed a “cold” about 3 days ago with sniffles. Her temperature is 37.8°C (100°F). Physical exam was completed with some difficulty because of the child's irritability. The only abnormalities are slight redness of the throat, a nose full of thick green mucus, and injected tympanic membranes. She denies nausea, vomiting, diarrhea, headache, or change in urine output.
**## EvaluationandManagementEMScoreSheet8985-2-1.pdf**
E/M Documentation Auditor’s Instructions
1. History
Refer to data section (table below) in order to quantify. After referring to data, circle the entry farthest to the RIGHT in the table, which
best describes the HPI, ROS and PFSH. If one column contains three circles, draw a line down that column to the bottom row to
identify the type of history. If no column contains three circles, the column containing a circle farthest to the LEFT, identifies the type
of history.
After completing this table which classifies the history, circle the type of history within the appropriate grid in Section 5.
HPI: Status of chronic conditions:
q 1 condition q 2 conditions q 3 conditions
q
Status of
1-2 chronic
Status of 3
chronic
conditions conditionsOR
HPI (history of present illness) elements:
q Location q Severity q Timing q Modifying factors
q Quality q Duration q Context q Associated signs and symptoms
q
Brief
(1-3)
Extended
(4 or more)
ROS (review of systems):
q Constitutional q Ears,nose, q GI q Integumentaryq Endo
(wt loss, etc) mouth, throat q GU (skin, breast) q Hem/lymph
q Eyes q Card/vasc q Musculo q Neuro q All/immuno
q Resp q Psych q All others negative
q
None
q
Pertinent to
problem
(1 system)
q
Extended
(2-9 systems)
*Complete
PFSH (past medical, family, social history) areas:
q Past history ( the patient's past experiences with illnesses, operation, injuries and treatments)
q Family history (a review of medical events in the patient's family, including diseases which may be
hereditary or place the patient at risk)
q Social history (an age appropriate review of past and current activities)
plete ROS: 10 or more systems or the pertinent positives and/or negatives of
q
None
q
Pertinent
(1 history area)
e**Complet
y(2 or 3 histor
areas)
PROBLEM
FOCUSED
EXP.PROB.
FOCUSED DETAILED -COMPRE
HENSIVE
q
T
O
R
Y
I
S
H
*Com
some systems with a statement “all others negative”.
**Complete PFSH: 2 history areas: a) Established Patients – Office (Outpatient) Care; b) Emergency Department.
3 history areas: a) New Patients – Office (Outpatient) Care, Domiciliary Care, Home Care; b) Initial Hospital Care;
c) Initial Hospital Observation; d) Initial Nursing Facility Care.
NOTE:For certain categories of E/M services that include only an interval history, it is not necessary to record
information about the PFSH. Please refer to procedure code descriptions.
2. Examination
Refer to data section (table below) in order to quantify. After referring to data, identify the type of examination.
Circle the type of examination within the appropriate grid in Section 5.
Limited to affected body area or organ system (one body area or system related to problem) PROBLEM FOCUSED EXAM
Affected body area or organ system and other symptomatic or related organ system(s)
(additional systems up to total of 7)
EXPANDED PROBLEM
FOCUSED EXAM
Extended exam of affected area(s) and other symptomatic or related organ system(s)
(additional systems up to total of 7 or more depth than above) DETAILED EXAM
General multi-system exam (8 or more systems) or complete exam of a single organ system
(complete single exam not defined in these instructions) COMPREHENSIVE EXAM
A
M
E
X
Body areas:
q Head, including face q Chest, including breasts and axillae
q Back, including spine qGenitalia, groin, buttocks
Organ systems:
q
q
Abdomen q Neck
Each extremity
q q q
1 body
area or
system
Up to 7
systems
Up to 7 8 or more
systems systems
q Constitutional q Ears,nose, q Resp q Musculo q Psych
) (e.g., vitals, gen app mouth, throat q GI q Skin
q Eyes q Cardiovascular q GU q Neuro
q Hem/lymph/imm
PROBLEM
FOCUSED
EXP.PROB.
FOCUSED DETAILED COMPRE-
HENSIVE
q
– 1 –
q
q
q
3. Medical Decision Making
Number of Diagnoses or Treatment Options
Identify each problem or treatment option mentioned in the record.
Enter the number in each of the categories in Column B in the table
below. (There are maximum number in two categories.)
Number of Diagnoses or Treatment Options
A B X C = D
Problem(s) Status Number Points Result
Self-limited or minor
(stable, improved or worsening) Max = 2 1
Est. problem (to examiner); stable, improved 1
Est. problem (to examiner); worsening 2
New problem (to examiner); no additional
workup planned
Max = 1
3
New prob. (to examiner); add. workup planned 4
TOTAL
Multiply the number in columns B & C and put the product in column D.
Enter a total for column D.
Bring total to line A in Final Result for Complexity (table below)
Amount and/or Complexity of Data Reviewed
For each category of reviewed data identified, circle the number in the points
column. Total the points.
Amount and/or Complexity of Data Reviewed
Reviewed Data Points
1
1
1
1
1
2
2
Review and/or order of clinical lab tests
Review and/or order of tests in the radiology section of CPT
Review and/or order of tests in the medicine section of CPT
Discussion of test results with performing physician
Decision to obtain old records and/or obtain history from
someone other than patient
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
Independent visualization of image, tracing or specimen itself
(not simply review of report)
TOTAL
Bring total to line C in Final Result for Complexity (table below)
Use the risk table below as a guide to assign risk factors. It is understood that the table below does not
contain all specific instances of medical care; the table is intended to be used as a guide. Circle the
most appropriate factor(s) in each category. The overall measure of risk is the highest level circled.
Enter the level of risk identified in Final Result for Complexity (table below).Risk of Complications and/or Morbidity or Mortality
Level of
Risk
Presenting Problem(s) Diagnostic Procedure(s)
Ordered
Management Options
Selected
Minimal
• 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
Low
• Two or more self-limited or minor problems
• One stable chronic illness, e.g., well controlled
hypertension or 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.,pulmonary
function tests
• Non-cardiovascular imaging studies with contrast,
e.g., barium enema
• Superficial needle biopsies
• Clincal 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 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
• Cardiovascular imaging studies with contrast and no
identified risk factors, e.g., arteriogram cardiac cath
• 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 addititives
• Closed treatment of fracture or dislocation without
manipulation
High
• One or more chronic illnesses with severe exacerbation,
progression, or side effects of treatment
• 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
• An abrupt change in neurologic status, e.g., seizure, TIA,
weakness or sensory loss
• Cardiovascular imaging studies with contrast 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
Final Result for Complexity
Draw a line down any column with 2 or 3 circles to identify the type of decision making in
that column. Otherwise, draw a line down the column with the 2nd circle from the left.
After completing this table, which classifies complexity, circle the type of decision
making within the appropriate grid in Section 5.
Final Result for Complexity
A Number diagnoses or
treatment options
≤ 1
Minimal
2
Limited
3
Multiple
≥ 4
Extensive
B Highest Risk Minimal Low Moderate High
C Amount and complexity
of data
≤ 1
Minimal
or low
2
Limited
3
Multiple
≥ 4
Extensive
Type of decision making STRAIGHT-
FORWARD
LOW
COMPLEX.
MODERATE
COMPLEX.
HIGH
COMPLEX.
4. Time
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.
Face-to-face in outpatient setting
Does documentation reveal total time? Time: Unit/floor in inpatient setting Yes No
Does documentation describe the content of counseling or coordinating care? Yes No
Does documentation reveal that more than half of the time was counseling or
coordinating care? Yes No
If all answers are "yes", select level based on time.
– 2 –
M
E
D
I
C
A
L
D
E
C
I
S
I
O
N
M
A
K
I
N
G
– Novitas Solutions Documentation Worksheet
– History Section
– Examination Section
– Medical Decision Making Section
– Time Section
– Level of Service Grids
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**PediatricSOAPTemplateandRubric-1.docx**
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