Code Component |
1995 Requirements |
1997 Requirements |
Draft Guidelines (June 2000) The Good News-- What’s Different |
|---|---|---|---|
Hx - History of Present Illness |
Specific requirements |
Specific requirements |
·Clearer requirements · Explicit recognition of medication monitoring |
Hx - Review of Systems |
Specific
body area or organ system requirements |
Specific body area or organ system requirements |
·Less required · Clearer · Examples are provided |
Hx - Past, Family, Social History |
Brief information required |
Brief information required |
No difference |
Physical Exam |
·Specifically referenced general multisystem exam · Description of single system exams inadequate · 4 levels · Requirements not clear |
·General multi-system exam and 10 single system exams · 4 levels · Very prescriptive · Confusing shading & bullets format · Requirements often not relevant |
·Physician tailors documentation to exam · Only 3 levels · Vignette examples · No bullets · No shading · Minimal counting · No irrelevant facts to record |
Medical Decision Making |
·4 levels · laundry list of examples not reflective of clinical assessments & plans |
·4 levels · Laundry list of examples not reflective of clinical assessments & plans |
·Only 3 levels · Physician tailors documentation to assessment & plan of treatment · Vignette examples |