Evaluation and Management Documentation Guidelines
Documentation Guidelines
1995 Documentation Guidelines: [Word] [PDF]
1997 Documentation Guidelines: [Word] [PDF]
| Level | History | Exam (95) | Exam (97) | MDM |
| 99201 | Problem Focused (PF) | Problem Focused (PF) | Problem Focused (PF) | Straightforward (SF) |
| 99202 | Expanded Problem Focused (EPF) | Expanded Problem Focused (EPF) | Expanded Problem Focused (EPF) | Straightforward(SF)/Low Complexity (LC) |
| 99203 | Detailed (D) | Detailed (D) | Detailed (D) | Low Complexity (LC) |
| 99204 | Comprehensive (C) | Comprehensive (C) | Comprehensive (C) | Moderate Complexity (MC) |
History Components
PF: Brief HPI (1-3 elements)
EPF: Brief HPI (1-3 elements) and Pertinent ROS (1)
D: Extended HPI (4 +); Extended ROS (2-9) and Pertinent PFSH (1)
Extended HPI (4+); Complete ROS (10) and Complement PFSH (3)
1995 Exam Components
PF: One body area/organ system
EPF: 2-7 Body areas/organ systems
D: 2-7 Body areas/organ systems