Evaluation and Management Documentation Guidelines

Documentation Guidelines

1995 Documentation Guidelines: [Word] [PDF]
1997 Documentation Guidelines: [Word] [PDF]

Office New Patient
LevelHistory Exam (95)Exam (97)MDM
99201Problem Focused (PF)Problem Focused (PF) Problem Focused (PF) Straightforward (SF)
99202Expanded Problem Focused (EPF) Expanded Problem Focused (EPF)Expanded Problem Focused (EPF) Straightforward(SF)/Low Complexity (LC)
99203Detailed (D) Detailed (D) Detailed (D)Low Complexity (LC)
99204Comprehensive (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