Established Patient – General Multisystem Exam CC/HPI:

Requirements must be met in 2 of 3 areas: (1) Hx (2) PE (3) Decisions

99213/Level III – Exp Problem Focused
99214/Level IV -- Detailed
HPI 99213 >= 1 OR 99214 >=3
99214 >=4:
 Location  Chr DZ
 Quality
 Duration  Chr DZ
 Timing
 Context  Chr DZ
 Modifying factors
 Associated S/S
ROS 99213 >= 1
99214 >=2
(pertinent system) Pain: _____ out of 10
Constitutional 
History

3 of 3 Required

Eyes  Tobacco:
ENT/Mouth  Last Td: _______
CV 
Resp  Allergies:
GI 
GU  Meds:
Musc 
Skin/Breasts 
Neuro 
Psych 
Endo 
Heme/Lymph 
Allergy/Immun  Vision Screen:
PFSH 99213: No PFSH LMP: OD 20/
99214 >=1:
PMH  OS 20/
FHx  Birth Control:
SHx  OU 20/
99213/Level III: >= 6 from any systems/areas
99214/Level IV: >=12 from >=2 systems/areas
Constitutional Ht: Wt: T: P: BP: / R: O2 Sat :

Eyes
Nurse Initials
ENT

Neck

Resp

CV

Chest (Breasts)
Exam

GI (Abd)

GU

Lymph

Musc

Skin
Patient Education given:  Verbal  Written
Neuro Check in Time:
Topic:  Meds  Disease  Other Appt Time:
Psych Exam Room:
Dr. Time:
 Understands  Needs repeat teaching Counseling Time:
Dictacted
Established Patient – Multisystem Exam

Alpine Medical Group Provider: _______________________ Date: _____-____-_____

Patient: _________________ DOB: ___ -___ - ___ Age:____

 99211/I 99212/II 99213/III 99214/IV 99215/V
Straightforward Low Complexity Moderate Complexity High Complexity
>=1 Point >=2 Points >=3 Points >=4 Points
(Max 2 pts minor probs) (Max 2 pts minor probs) (Max 2 pts minor probs) (Max 2 pts minor probs)
 Minor prob 1  Minor prob 1  Minor prob 1  Minor prob 1
Diagnosis

 Minor prob 1  Minor prob 1  Minor prob 1  Minor prob 1

 Estab prob-stable 1  Estab prob-stable 1  Estab prob-stable 1  Estab prob-stable 1
 Estab prob-stable 1  Estab prob-stable 1  Estab prob-stable 1  Estab prob-stable 1
 Estab prob-worse 2  Estab prob-worse 2  Estab prob-worse 2  Estab prob-worse 2
 Estab prob-worse 2  Estab prob-worse 2  Estab prob-worse 2  Estab prob-worse 2
Max 3 pts for new probs-stable Max 3 pts for new probs-stable Max 3 pts for new probs-stable Max 3 pts for new probs-stable
 New prob-stable 3  New prob-stable 3  New prob-stable 3  New prob-stable 3
 New prob-need w/u 4  New prob-need w/u 4  New prob-need w/u 4  New prob-need w/u 4
TOTAL TOTAL TOTAL TOTAL
>=1 Point >=2 Points >=3 Points >=4 Points
 Order/study labs 1  Order/study labs 1  Order/study labs 1  Order/study labs 1
 Order/study X-rays 1  Order/study X-rays 1  Order/study X-rays 1  Order/study X-rays 1
 Order/study med tests 1  Order/study med tests 1  Order/study med tests 1  Order/study med tests 1
 Discussed results w/ 1  Discussed results w/ 1  Discussed results w/ 1  Discussed results w/ 1
Data

testing Dr. testing Dr. testing Dr. testing Dr.

 Order old recs/add Hx 1  Order old recs/add Hx 1  Order old recs/add Hx 1  Order old recs/add Hx 1
  Summary of review of old 2  Summary of review of old 2  Summary of review of old 2  Summary of review of old 2
recs/add Hx recs/add Hx recs/add Hx recs/add Hx
 View X-ray, tracing or 2  View X-ray, tracing or 2  View X-ray, tracing or 2  View X-ray, tracing or 2
Decision Making

2 of 3 Required

slide prev interp by other Dr. slide prev interp by other Dr. slide prev interp by other Dr. slide prev interp by other Dr.
TOTAL TOTAL TOTAL TOTAL
Risk >=1 Point >=1 Point >=1 Point >=1 Point
 1 minor prob (cold, bug bite)  2+ minor probs  1+ chronic prob-mild incr  1+ chronic prob-sev incr
 1 chronic prob-stable  2+ chronic probs-stable  Chronic prob-life threat
 Acute prob-uncomplicated  Acute prob-systemic  Acute prob-life threat
Problems

(allergy, UTI, sprain) (pyelo, pneumo)

 Acute injury-complicated  Acute Mental status change
(head injury w/ brief LOC) (TIA, Seizure, weakness)
  New prob-uncert Px
(breast lump)

 X-ray  Non-CV contrast studies  CV contrast studies  CV contrast studies

(No risk factors) (With risk factors)
Procedures

 Labs  PFT  Endoscopy (No risk factors)  Endoscopy (With risk factors)
 EKG  Skin Bx  Deep needle Bx
 UA  Needle Bx – superficial  Incision Bx
 KOH  Puncture-arterial  EST
 FST
 Body cavity fluids

 Rest  OTC drugs (list OTC meds)  Rx drugs (list meds)  Drugs-intensive monitor
 Gargle  PT  Parental Tx
 Fracture Tx-closed (no manip)  Fracture Tx-closed (w/ manip)
Management

 Bandages-elastic  OT  DNR decision or deescalate

 Superficial dressings  IVF (no additives)  IVF (w./ additives) care due to poor Px
 Minor surg (no risk factors)  Minor surg (w/ risk factors)
 Major surg-elective  Major surg-elective
(incl endosc; no risk factors) (incl endosc; with risk factors)
 Major surg-emergent
(incl endosc)

5-min 10-min 15-min 25-min 40-min

i
T

Documentation must include: Dx, Description of Counseling/Coordination, Total Time, Who was Present.
 When more than 50% of the face-to-face time with the patient was spent in addressing counseling components, the visit may be coded based on time if the
CHART DOCUMENTATION supports the time. The documentation must list the total time of the encounter and that coding was based on counseling regarding…
 Instructions for management
 Diagnostic results  Risks and Benefit of Tx option
 Risk factor reduction  Impressions
 Prognosis  Patient & Family education
Importance of compliance w/ chosen Tx options

Alpine Medical Group Provider: _______________________ Date: _____-____-_____

Patient: _________________ DOB: ___ -___ - ___ Age:____