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For purposes of examination, the following organ systems are recognized: Constitutional (e.g., vital signs, general appearance) Eyes Ears, nose, mouth, and throat Cardiovascular Respiratory Gastrointestinal Genitourinary Musculoskeletal Skin Neurologic Psychiatric Hematologic/lymphatic/immunologic The extent of examinations performed and documented is dependent upon clinical judgment and the nature of the presenting problem(s). They range from limited examinations of single body areas to general multi-system or complete single organ system examinations. DG: Specific abnormal and relevant negative findings of the examination of the affected or symptomatic body area(s) or organ system(s) should be documented. A notation of "abnormal” without elaboration is insufficient. DG: Abnormal or unexpected findings of the examination of the unaffected or asymptomatic body area(s) or organ system(s) should be described. DG: A brief statement or notation indicating "negative" or "normal" is sufficient to document normal findings related to unaffected area(s) or asymptomatic organ system(s). DG: The medical record for a general multi-system examination should include findings about 8 or more of the 12 organ systems. 10 Medicare Physician Guide: A Resource for Residents, Practicing Physicians and Other Health Care Professionals 107
C. DOCUMENTATION OF THE COMPLEXITY OF MEDICAL DECISION MAKING The levels of E/M services recognize four types of medical decision making (straightforward, low complexity, moderate complexity, and high complexity). Medical decision making refers to the complexity of establishing a diagnosis and/or selecting a management option as measured by: the number of possible diagnoses and/or the number of management options that must be considered; the amount and/or complexity of medical records, diagnostic tests, and/or other information that must be obtained, reviewed, and analyzed; and the risk of significant complications, morbidity, and/or mortality, as well as comorbidities associated with the patient's presenting problem(s), the diagnostic procedure(s) and/or the possible management options. The chart below shows the progression of the elements required for each level of medical decision making. To qualify for a given type of decision making, two of the three elements in the table must be either met or exceeded. Number of diagnoses or management options Amount and/or complexity of data to be reviewed Risk of complications and/or morbidity or mortality Type of decision making Minimal Minimal or None Minimal Straightforward Limited Limited Low Low Complexity Multiple Moderate Moderate Moderate Complexity Extensive Extensive High High Complexity Each of the elements of medical decision making is described on the following page. NUMBER OF DIAGNOSES OR MANAGEMENT OPTIONS The number of possible diagnoses and/or the number of management options that must be considered is based on the number and types of problems addressed during the encounter, the complexity of establishing a diagnosis and the management decisions that are made by the physician. 11 Medicare Physician Guide: A Resource for Residents, Practicing Physicians and Other Health Care Professionals 108
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Medicare Physician Guide A Resource
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ICD-9-CM Notice The International C
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MEDICARE PHYSICIAN FEE SCHEDULE ...
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CHAPTER ONE INTRODUCTION TO THE MED
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THE MEDICARE PROGRAM The Medicare P
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Where to Find Additional Informatio
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Accept the Medicare allowed amount
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