1995 DocumentationTION GuidelinesIDELINES for ­Evaluation and ­ManaALUATION AND mANAgement Services ||||||||||| 365 Appendix A CPT copyright 2015 American Medical Association. All rights reserved. •DG: Relevant findings from the review of old records and/or the receipt of additional history from the family, caretaker, or other source should be documented. If there is no relevant information beyond that already obtained, that fact should be documented. A notation of “old records reviewed” or “­additional history obtained from family” without elaboration is insufficient. •DG: The results of discussion of laboratory, radiology, or other diagnostic tests with the physician who performed or interpreted the study should be documented. •DG: The direct visualization and independent interpretation of an image, tracing, or specimen previously or subsequently interpreted by another physician should be documented. Risk of Significant Complications, Morbidity, and/or Mortality The risk of significant complications, morbidity, and/or mortality is based on the risks associated with the presenting problem(s), the diagnostic procedure(s), and the possible management options. •DG: Co-morbidities/underlying diseases or other factors that increase the complexity of medical decision making by increasing the risk of complications, morbidity, and/or mortality should be documented. •DG: If a surgical or invasive diagnostic procedure is ordered, planned, or scheduled at the time of the E/M encounter, the type of procedure (eg, laparoscopy) should be documented. •DG: If a surgical or invasive diagnostic procedure is performed at the time of the E/M encounter, the specific procedure should be documented. •DG: The referral for or decision to perform a surgical or invasive diagnostic procedure on an urgent basis should be documented or implied. The following table may be used to help determine whether the risk of significant complications, morbidity, and/or mortality is minimal, low, moderate, or high. Because the determination of risk is complex and not readily quantifiable, the table includes common clinical examples rather than absolute measures of risk. 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 immedi- ately following any procedures or treatment. The highest level of risk in any one category (presenting problem(s), diagnostic procedure(s), or management options) determines the overall risk. D. Documentation of an Encounter Dominated by Counseling or Coordination of Care In the case where counseling and/or coordination of care dominates (more than 50%) the physician/ patient and/or family encounter (face-to-face time in the office or other outpatient setting or floor/unit time in the hospital or nursing facility), time is considered the key or controlling factor to qualify for a particular level of E/M services. •DG: If the physician elects to report the level of service based on counseling and/or coordination of care, the total length of time of the encounter (face-to-face or floor time, as appropriate) should be docu- mented and the record should describe the counseling and/or activities to coordinate care. Table of Risk Level of Risk Presenting Problem(s) Diagnostic Procedure(s) Ordered Options ­Management Selected Minimal EEOne self-limited or minor problem, eg, cold, insect bite, tinea corporis EELaboratory tests requiring venipuncture EEChest x-rays EEEKG/EEG EEUrinalysis EEUltrasound, eg, echocardiography EEKOH prep EERest EEGargles EEElastic bandages EESuperficial dressings
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