SOAP NOTE on Musculoskeletal/Neuro

E/M Documentation Auditor’s Instructions

1. History Refer to data section (table below) in order to quantify. After referring to data, circle the entry farthest to the RIGHT in the table, which best describes the HPI, ROS and PFSH. If one column contains three circles, draw a line down that column to the bottom row to identify the type of history. If no column contains three circles, the column containing a circle farthest to the LEFT, identifies the type of history.

After completing this table which classifies the history, circle the type of history within the appropriate grid in Section 5.

HPI: Status of chronic conditions: q 1 condition q 2 conditions q 3 conditions

q Status of 1-2 chronic

Status of 3 chronic

conditions conditionsOR

HPI (history of present illness) elements: q Location q Severity q Timing q Modifying factors

q Quality q Duration q Context q Associated signs and symptoms

q Brief (1-3)

Extended (4 or more)

ROS (review of systems):

q Constitutional q Ears,nose, q GI q Integumentaryq Endo (wt loss, etc) mouth, throat q GU (skin, breast) q Hem/lymph

q Eyes q Card/vasc q Musculo q Neuro q All/immuno q Resp q Psych q All others negative

q None

q Pertinent to problem

(1 system)

q

Extended (2-9 systems)

*Complete

PFSH (past medical, family, social history) areas: q Past history ( the patient's past experiences with illnesses, operation, injuries and treatments) q Family history (a review of medical events in the patient's family, including diseases which may be

hereditary or place the patient at risk) q Social history (an age appropriate review of past and current activities)

plete ROS: 10 or more systems or the pertinent positives and/or negatives of

q None

q Pertinent

(1 history area) e**Complet y(2 or 3 histor

areas)

PROBLEM FOCUSED

EXP.PROB. FOCUSED DETAILED -COMPRE

HENSIVE

q

T O

R Y

I S

H

*Com some systems with a statement “all others negative”.

**Complete PFSH: 2 history areas: a) Established Patients - Office (Outpatient) Care; b) Emergency Department.

3 history areas: a) New Patients - Office (Outpatient) Care, Domiciliary Care, Home Care; b) Initial Hospital Care; c) Initial Hospital Observation; d) Initial Nursing Facility Care.

NOTE:For certain categories of E/M services that include only an interval history, it is not necessary to record information about the PFSH. Please refer to procedure code descriptions.

2. Examination

Refer to data section (table below) in order to quantify. After referring to data, identify the type of examination. Circle the type of examination within the appropriate grid in Section 5.

Limited to affected body area or organ system (one body area or system related to problem) PROBLEM FOCUSED EXAM

Affected body area or organ system and other symptomatic or related organ system(s) (additional systems up to total of 7)

EXPANDED PROBLEM FOCUSED EXAM

Extended exam of affected area(s) and other symptomatic or related organ system(s) (additional systems up to total of 7 or more depth than above) DETAILED EXAM

General multi-system exam (8 or more systems) or complete exam of a single organ system (complete single exam not defined in these instructions) COMPREHENSIVE EXAM

A M

E X

Body areas: q Head, including face q Chest, including breasts and axillae q Back, including spine qGenitalia, groin, buttocks

Organ systems:

q

q

Abdomen q Neck Each extremity

q q q 1 body area or system

Up to 7 systems

Up to 7 8 or more systems systems

q Constitutional q Ears,nose, q Resp q Musculo q Psych ) (e.g., vitals, gen app mouth, throat q GI q Skin

q Eyes q Cardiovascular q GU q Neuro q Hem/lymph/imm

PROBLEM FOCUSED

EXP.PROB. FOCUSED DETAILED COMPRE-

HENSIVE

q

- 1 -

q

q

q

3. Medical Decision Making

Number of Diagnoses or Treatment Options

Identify each problem or treatment option mentioned in the record. Enter the number in each of the categories in Column B in the table below. (There are maximum number in two categories.)

Number of Diagnoses or Treatment Options A B X C = D

Problem(s) Status Number Points Result

Self-limited or minor (stable, improved or worsening) Max = 2 1 Est. problem (to examiner); stable, improved 1

Est. problem (to examiner); worsening 2

New problem (to examiner); no additional workup planned

Max = 1

3

New prob. (to examiner); add. workup planned 4

TOTAL Multiply the number in columns B & C and put the product in column D. Enter a total for column D.

Bring total to line A in Final Result for Complexity (table below)

Amount and/or Complexity of Data Reviewed

For each category of reviewed data identified, circle the number in the points column. Total the points.

Amount and/or Complexity of Data Reviewed Reviewed Data Points

1

1

1

1

1

2

2

Review and/or order of clinical lab tests

Review and/or order of tests in the radiology section of CPT

Review and/or order of tests in the medicine section of CPT

Discussion of test results with performing physician

Decision to obtain old records and/or obtain history from someone other than patient

Review and summarization of old records and/or obtaining history from someone other than patient and/or discussion of case with another health care provider

Independent visualization of image, tracing or specimen itself (not simply review of report)

TOTAL Bring total to line C in Final Result for Complexity (table below)

Use the risk table below as a guide to assign risk factors. It is understood that the table below does not contain all specific instances of medical care; the table is intended to be used as a guide. Circle the most appropriate factor(s) in each category. The overall measure of risk is the highest level circled. Enter the level of risk identified in Final Result for Complexity (table below).Risk of Complications and/or Morbidity or Mortality

Level of Risk

Presenting Problem(s) Diagnostic Procedure(s) Ordered

Management Options Selected

Minimal • One self-limited or minor problem,

e.g., cold, insect bite, tinea corporis

• Laboratory tests requiring venipuncture • Chest x-rays • EKG/EEG • Urinalysis • Ultrasound, e.g., echo • KOH prep

• Rest • Gargles • Elastic bandages • Superficial dressings

Low

• Two or more self-limited or minor problems • One stable chronic illness, e.g., well controlled

hypertension or non-insulin dependent diabetes, cataract, BPH

• Acute uncomplicated illness or injury, e.g., cystitis, allergic rhinitis, simple sprain

• Physiologic tests not under stress, e.g.,pulmonary function tests

• Non-cardiovascular imaging studies with contrast, e.g., barium enema

• Superficial needle biopsies • Clincal laboratory tests requiring arterial puncture • Skin biopsies

• Over-the-counter drugs • Minor surgery with no identified risk factors • Physical therapy • Occupational therapy • IV fluids without additives

Moderate

• One or more chronic illnesses with mild exacerbation, progression, or side effects of treatment

• Two or more stable chronic illnesses • Undiagnosed new problem with uncertain prognosis, e.g., lump in breast

• Acute illness with systemic symptoms, e.g., pyelonephritis, pneumonitis, colitis

• Acute complicated injury, e.g., head injury with brief loss of consciousness

• Physiologic tests under stress, e.g., cardiac stress test, fetal contraction stress test

• Diagnostic endoscopies with no identified risk factors • Deep needle or incisional biopsy • Cardiovascular imaging studies with contrast and no

identified risk factors, e.g., arteriogram cardiac cath • Obtain fluid from body cavity, e.g., lumbar puncture,

thoracentesis, culdocentesis

• Minor surgery with identified risk factors • Elective major surgery (open, percutaneous or

endoscopic) with no identified risk factors • Prescription drug management • Therapeutic nuclear medicine • IV fluids with addititives • Closed treatment of fracture or dislocation without

manipulation

High

• One or more chronic illnesses with severe exacerbation, progression, or side effects of treatment

• Acute or chronic illnesses or injuries that may pose a threat to life or bodily function, e.g., multiple trauma, acute MI, pulmonary embolus, severe respiratory distress, progressive severe rheumatoid arthritis, psychiatric illness with potential threat to self or others, peritonitis, acute renal failure

• An abrupt change in neurologic status, e.g., seizure, TIA, weakness or sensory loss

• Cardiovascular imaging studies with contrast with identified risk factors

• Cardiac electrophysiological tests • Diagnostic endoscopies with identified risk factors • Discography

• Elective major surgery (open, percutaneous or endoscopic with identified risk factors)

• Emergency major surgery (open, percutaneous or endoscopic)

• Parenteral controlled substances • Drug therapy requiring intensive monitoring for toxicity • Decision not to resuscitate or to de-escalate care

because of poor prognosis

Final Result for Complexity Draw a line down any column with 2 or 3 circles to identify the type of decision making in that column. Otherwise, draw a line down the column with the 2nd circle from the left. After completing this table, which classifies complexity, circle the type of decision making within the appropriate grid in Section 5.

Final Result for Complexity

A Number diagnoses or treatment options

≤ 1 Minimal

2 Limited

3 Multiple

≥ 4 Extensive

B Highest Risk Minimal Low Moderate High

C Amount and complexity of data

≤ 1 Minimal or low

2 Limited

3 Multiple

≥ 4 Extensive

Type of decision making STRAIGHT- FORWARD

LOW COMPLEX.

MODERATE COMPLEX.

HIGH COMPLEX.

4. Time

If the physician documents total time and suggests that counseling or coordinating care dominates (more than 50%) the encounter, time may determine level of service. Documentation may refer to: prognosis, differential diagnosis, risks, benefits of treatment, instructions, compliance, risk reduction or discussion with another health care provider.

Face-to-face in outpatient setting Does documentation reveal total time? Time: Unit/floor in inpatient setting Yes No

Does documentation describe the content of counseling or coordinating care? Yes No

Does documentation reveal that more than half of the time was counseling or coordinating care? Yes No

If all answers are "yes", select level based on time.

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M E D I C A L D E C I S I O

N M

A K I N G

5. L E V E L O F S E R V I C E

New Office, Outpatient and Emergency Room New Office / Outpatient / ER Established Office / Outpatient Requires 3 components within shaded area Requires 2 components within shaded area

History PF

ER: PF EPF

ER: EPF D

ER: EPF C

ER: D C

ER: C Minimal problem that may not require presence of physician

PF EPF D C

Examination PF

ER: PF

EPF

ER: EPF

D

ER: EPF

C

ER: D

C

ER: C PF EPF D C

Complexity of medical decision

SF ER: SF

SF ER: L

L ER: M

M ER: M

H ER: H SF L M H

Average time (minutes)

ER has no average time

10 New (99201)

ER (99281)

20 New (99202)

ER (99282)

30 New (99203)

ER (99283)

45 New (99204)

ER (99284)

60 New (99205)

ER (99285)

5 (99211)

10 (99212)

15 (99213)

25 (99214)

40 (99215)

Level I II III IV V I II III IV V

Hospital Care Initial Hospital/Observation Subsequent Hospital/Observation Requires 3 components within shaded area Requires 2 components within shaded area

History D/C C C PF interval EPF interval D interval

Examination D/C C C PF EPF D Complexity of medical

decision SF/L M H SF/L M H

Average time (minutes) 30 Init hosp (99221) 30 Init observ Care

(99218)

50 Init hosp (99222) 50 Init observ Care

(99219)

70 Init hosp (99223) 70 Init observ Care

(99220)

15 Sub hosp (99231) 15 Sub observ care

(99224)

25 Sub hosp (99232) 25 Sub observ care

(99225)

35 Sub hosp (99233) 35 Sub observ care

(99226)

Level I II III I II III

Nursing Facility Care Initial Nursing Facility

Requires 3 components within shaded area Subsequent Nursing Facility Requires 2 components within shaded area

Other Nursing Facility (Annual Assessment)

Requires 3 components within shaded area

History D/C C C PF interval EPF interval D interval C interval D interval

Examination D/C C C PF EPF D C C

Complexity of medical decision SF/L M H SF L M H L/M

Average time (minutes) 25 99304

35 99305

45 99306

10 99307

15 99308

25 99309

35 99310

30 99318

Level I II III I II III IV

Domiciliary, Rest Home (eg, Boarding Home), or Custodial Care Services and Home Care

Requires 3 components within shaded area Requires 2 onents within shaded area

History PF EPF D C C PF interval EPF interval D interval C interval

Examination PF EPF D C C PF EPF D C Complexity of

medical decision SF L M M H SF L M M/H Average time (minutes)

20 Domiciliary (99324) Home care (99341)

30 Domiciliary (99325) Home care (99342)

45 Domiciliary (99326) Home care (99343)

60 Domiciliary (99327) Home care (99344)

75 Domiciliary (99328) Home care (99345)

15 Domiciliary (99334) Home care (99347)

25 Domiciliary (99335) Home care (99348)

40 Domiciliary (99336) Home care (99349)

60 Domiciliary (99337) Home care (99350)

Level I II III IV V I II III IV PF = Problem focused EPF = Expanded problem focused D = Detailed C = Comprehensive SF = Straightforward L = Low M = Moderate H = High

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Establishe dcomp

New