UNIVERSITY INTERNAL MEDICINE ASSOCIATES LLP
SUBSEQUENT INPATIENT VIST (FOLLOW-UP)
TEMPLATE

Level 2 (99232)

	History: Expanded Problem-Focused
		One to three history elements
		One system element reviewed
		No Past, Family, or Social history

	Exam: At physician discretion
		(>/= 6 elements, if no history)

	Medical Decision Making (A/P): MODERATE LEVEL
		3 stable problems, no changes OR
		one new problem requiring no w/u OR
		one old problem that is worse and one stable problem
		Moderate Risk category = on prescription meds

Level 3 (99233)

	History: Detailed
		Four history elements (or status of 3 chronic problems)
		2 systems elements (minimum)

	Exam:  At physician discretion
		(>/= 12 elements if no history)

	Medical Decision Making (A/P): HIGH LEVEL
		4 stable problems, no changes OR
		one new problem requiring w/u OR
		one old problem that is worse and two stable problems

		High Risk category = on parenteral narcotics or
		DNR discussion, or potentially life-threatening
		problem. etc.

INITIAL INPATIENT VISIT
TEMPLATE

Level 2 (99222)

	History: Comprehensive
		2 four history elements or status of 3 chronic conditions
		10 systems reviewed ("all others negative")
		One element from Past, Family, and Social history

		Exam: 2 bullets from 9 body areas

	Medical Decision Making (A/P): MODERATE LEVEL
		3 stable problems, no changes OR
		one new problem requiring no w/u OR
		one old problem that is worse and one stable problem
		Moderate Risk category = on prescription meds

Level 3 (99223)
	History: Comprehensive
		2 four history elements or status of 3 chronic conditions
		10 systems reviewed ("all others negative")
		One element from Past, Family, and Social history

		Exam: 2 bullets from 9 body areas

		Medical Decision Making (A/P): HIGH LEVEL
			4 stable problems, no changes OR
			one new problem requiring w/u OR
			one old problem that is worse and two stable problems

			Data includes lab, x-ray, and either old chart review,
			OR personal review of x-ray, OR consult, OR history
			from other than patient

			High Risk category = on parenteral narcotics or DNR
			discussion, or potentially life-threatening problem, etc.

ESTABLISHED OUTPATIENT VISIT
TEMPLATE

Level 3 (99213)
	History: Expanded Problem Focused
		One history element (minimum)
		One system reviewed (minimum)
		No Past, Family, and Social History

	Exam: At physician discretion
		(>/= 6 bullets, if no history)

	Medical Decision Making (A/P): LOW LEVEL
		2 established - stable problems, no changes OR
		1 established - stable problem. worsening

		Low Risk Category = NIDDM. We||-contro|led HTN, OTC drugs

Level 4 (99214)
	History: Detailed
		2 four history elements or status of 3 chronic conditions
		2 systems reviewed (minimum)
		One element from Past, Family. or Social History

	Exam: At physician discretion
		(12 bullets. if no history)

	Medical Decision Making (A/P): MODERATE LEVEL
		3 established - stable problems, no changes OR
		one new problem requiring no w/u OR
		one old problem, worsening and one stable problem

		Mod. Risk Category = on prescr. meds, 2 stable chron. Illn.

Level 5 (99215)

	History: Comprehensive
		2 four history elements or status of 3 chronic conditions
		10 systems reviewed or "all others negative"
		Two elements from Past, Family, and Social History

	Exam: At physician discretion
		(2 bullets from 9 areas / systems, if no history)

	Medical Decision Making (A/P): HIGH LEVEL
		4 established stable problems, no changes OR
		one new problem requiring w/u OR
		one old problem worsening and two stable problems

		Data includes lab, x-ray, and either old chart review,
		OR personal review of x-ray. OR consult. OR history
		from other than patient

		High Risk category = on parenteral narcotics, DNR
		discussion. or potentially life~threatening problem

NEW OUTPATIENT VISIT
TEMPLATE

Level 3 (99203)

	History: Detailed
		>/= four history elements or status of 3 chronic conditions
		2 systems reviewed (minimum)
		One element from Past, Family, OR Social history

	Exam: Detailed
		12 bullets

	Medical Decision Making (A/P): LOW LEVEL
		2 established — stable problems, no changes OR
		1 established - stable problem, worsening

		Low Risk Category = NIDDM, Well-controlled HTN, OTC drugs

Level 4 (99204)

	History: Comprehensive
		>/= four history elements or status of 3 chronic conditions
		10 systems reviewed or ''all others negative"
		One element each from Past, Family, and Social history

	Exam: Comprehensive
		2 bullets from 9 areas / systems

	Medical Decision Making (A/P): MODERATE LEVEL
		3 established — stable problems, no changes OR
		one new problem requiring no w/u OR
		one old problem, worsening and one stable problem
		
		Mod. Risk Category = on prescr. meds, 2 stable chron. illn.

Level 5 (99205)

	History: Comprehensive
		>/= four history elements or status of 3 chronic conditions
		10 systems reviewed or ''all others negative"
		One element each from Past, Family, and Social history

	Exam: Comprehensive
		2 bullets from 9 areas / systems

	Medical Decision Making (A/P): HIGH LEVEL
		4 established — stable problems, no changes OR
		one new problem requiring w/u OR
		one old problem worsening and two stable problems

		Data includes lab, x-ray, and either old chart review,
		OR personal review of x-ray, OR consult, OR history
		from other than patient

		High Risk category = on parenteral narcotics, DNR
		discussion, or potentially life-threatening problem