A Resource for

 Residents, Practicing Physicians,

 and 

Other 

Health Care 

Professionals

A Resource for

 Residents, Practicing 

 Physicians,

 and 

Other 

Health Care 

Professionals

Facilitator’s Guide Facilitator’s Guide

Medicare Physician Guide Medicare Physician Guide

ICN: 006352 October 2009
FACILITATOR’S

GUIDE

COMPANION TO 

MEDICARE PHYSICIAN GUIDE: 

A RESOURCE FOR RESIDENTS, 

PRACTICING PHYSICIANS, 

AND OTHER HEALTH 

CARE PROFESSIONALS

October 2009

ICN: 006352
00 Table of Contents

TABLE OF CONTENTS

SUBJECT FILE NAME

Table of Contents 00 Table of Contents

Preface 01 Preface 

Instructions for Facilitators 02 Instructions for Facilitators

Promotional Flyer 03 Promotional Flyer

Program Sign-In Sheet 04 Program Sign-In Sheet

3-Hour Medicare Program Training 

Module 

05 3 Hour Medicare Program Training 

Module 

Pre-Assessments and PostAssessments – Chapter 106 Chapter 1 Pre Post Assessment 

Pre-Assessments and PostAssessments – Chapter 207 Chapter 2 Pre Post Assessment 

Pre-Assessments and PostAssessments – Chapter 308 Chapter 3 Pre Post Assessment 

Pre-Assessments and PostAssessments – Chapter 409 Chapter 4 Pre Post Assessment 

Pre-Assessments and PostAssessments – Chapter 510 Chapter 5 Pre Post Assessment 

Pre-Assessments and PostAssessments – Chapter 611 Chapter 6 Pre Post Assessment 

Pre-Assessments and PostAssessments – Chapter 712 Chapter 7 Pre Post Assessment 

Pre- and Post-Assessment Master 

Answer Keys

13 Master Answer Keys

Course Evaluation (learners) 14 Course Evaluation 

Reference Information (hand outs) 15 Reference

Request for CMS-Led In-Person 

Course

16 Request for Course
01 Preface 1

PREFACE

Physician and health care professional outreach has been, and continues to be, 

one of the Centers for Medicare & Medicaid Services’ (CMS) top priorities. The 

Medicare Resident, Practicing Physician, and Other Health Care Professional 

Training Program is a customized instructor-led course that has been delivered 

to learners at medical schools and other organizations throughout the United 

States. The goal of this program is to provide general information and resources 

to residents, practicing physicians, and other health care professionals who are 

new to the Medicare Program. The Medicare Resident, Practicing Physician, and 

Other Health Care Professional Training Program is open to all health care 

professionals. The primary target audience of this program is residents who are 

preparing to establish their own medical practice within six months of attending a

Medicare Resident, Practicing Physician, and Other Health Care Professional 

Training Program course. 

Disclaimer

This guide was current at the time it was published or uploaded onto the web. 

Medicare policy changes frequently so links to the source documents have been 

provided within the document for your reference. 

This guide was prepared as a tool to assist providers and is not intended to grant 

rights or impose obligations. Although every reasonable effort has been made to 

assure the accuracy of the information within these pages, the ultimate 

responsibility for the correct submission of claims and response to any 

remittance advice lies with the provider of services. CMS employees, agents, and 

staff make no representation, warranty, or guarantee that this compilation of 

Medicare information is error-free and will bear no responsibility or liability for the 

results or consequences of the use of this guide. This guide is a general 

summary that explains certain aspects of the Medicare Program, but is not a 

legal document. The official Medicare Program provisions are contained in the 

relevant laws, regulations, and rulings.

Medicare Learning Network

The Medicare Learning Network (MLN) is the brand name for official CMS 

educational products and information for Medicare fee-for-service providers. For 

additional information visit the Medicare Learning Network’s web page at 

http://www.cms.hhs.gov/MLNGenInfo on the CMS website.
2 01 Preface

CPT Notice and Disclaimer

CPT codes, descriptions, and other data only are copyright 2008 American 

Medical Association. All Rights Reserved. CPT is a registered trademark of the 

American Medical Association. Applicable FARS/DFARS Restrictions Apply to 

Government Use. Fee schedules, relative value units, conversion factors and/or 

related components are not assigned by the AMA, are not part of CPT, and the 

AMA is not recommending their use. The AMA does not directly or indirectly 

practice medicine or dispense medical services. The AMA assumes no liability 

for data contained or not contained herein.

ICD-9-CM Notice

The International Classification of Diseases, 9th Revision, Clinical Modification 

(ICD-9-CM) is published by the United States Government. A CD-ROM, which 

may be purchased through the Government Printing Office, is the only official 

Federal government version of the ICD-9-CM. ICD-9-CM is an official Health 

Insurance Portability and Accountability Act standard.
INSTRUCTIONS FOR FACILITATORS 

The Centers for Medicare & Medicaid Services (CMS) Medicare Learning 

Network (MLN) has developed the following materials specifically for facilitators 

who plan to conduct a Medicare Resident, Practicing Physician, and Other 

Health Care Professional Training Program course: 

1) Medicare Physician Guide: A Resource for Residents, Practicing 

Physicians, and Other Health Care Professionals 

This comprehensive guide, which is available in print, CD-ROM, and 

downloadable formats, offers learners an overview of the Medicare 

Program. 

2) Facilitator’s Guide 

This guide, which is available in CD-ROM and downloadable formats, 

provides everything needed to prepare for and conduct a Medicare 

Resident, Practicing Physician, and Other Health Care Professional 

Training Program course. Included are the following materials: 

• Promotional Flyer; 

• Program Sign-In Sheet; 

• 3-Hour Medicare Program Training Module; 

• Pre- and Post-Assessments; 

• Pre- and Post-Assessment Master Answer Keys; 

• Course Evaluation (to be completed by learners); 

• Reference Information (hand outs); and 

• Request for Centers for Medicare & Medicaid Services-Led InPerson Course. 

3) Video – Medicare Resident, Practicing Physician, and Other Health 

Care Professional Training: An Introduction 

Short video, available in DVD format, offers learners basic Medicare 

information and resources. 

These materials are available free of charge from the MLN. To place your order, 

visit http://www.cms.hhs.gov/MLNGenInfo on the CMS website. On this web 

page, scroll down to "Related Links Inside CMS" and select "MLN Product 

Ordering Page." 

02 Instructions for Facilitators 1
Course Administration 

The Medicare Resident, Practicing Physician, and Other Health Care 

Professional Training Program is a customized instructor-led course that has 

been delivered to learners at medical schools and other organizations throughout 

the United States. The goal of this program is to provide general information and 

resources to residents, practicing physicians, and other health care professionals 

who are new to the Medicare Program. 

Audience 

All health care professionals may attend this course. The primary target audience 

of this program is residents who are preparing to establish their own medical 

practice within six months of attending a Medicare Resident, Practicing 

Physician, and Other Health Care Professional Training Program course. 

Software Requirements

Course documents were developed with the following software: 

• Adobe Acrobat 8.0; 

• Microsoft PowerPoint 2007; and 

• Microsoft Word 2007. 

 

You must have one of the following software versions to download and 

customize the course: 

• Adobe Acrobat 7.0; 

• Microsoft PowerPoint 2003 or above; and 

• Microsoft Word 2003 or above. 

Pre- Assessment

Prior to conducting the course, ask learners to complete the appropriate 

Pre-Assessment, Word file(s) labeled “06 Chapter 1 Pre Post Assessment” – 

“12 Chapter 7 Pre Post Assessment.” The purpose of the Pre-Assessment is to 

determine learners’ knowledge of Medicare prior to attending the course. 

Please make copies of completed Pre-Assessment answer sheets for your 

locked, confidential file and mail originals to: 

Ann Palmer 

Centers for Medicare & Medicaid Services 

7500 Security Boulevard, Mail Stop C4-13-07 

 Baltimore, MD 21244 

2 02 Instructions for Facilitators 
Learning Objectives

Learning objectives reflect what the learners will achieve as a result of attending 

this course. Learning objectives also assist facilitators in determining the 

information that should be included in the course. The 3-Hour Medicare Program 

Training Module learning objectives are listed below.

Chapter 1 – Introduction to the Medicare Program 

• Identify Medicare’s four parts. 

• Determine the individuals who are eligible for Medicare Part A and Part B, 

Medicare Advantage, and the prescription drug plan. 

• Identify the organizations that impact the Medicare Program. 

Chapter 2 – Becoming a Medicare Provider or Supplier 

• Identify Part A and Part B providers and suppliers. 

• Define the Medicare physician and practitioner. 

• Describe the Medicare Program enrollment process. 

• Identify how providers and suppliers can promote cultural competency. 

 

Chapter 3 – Medicare Reimbursement 

• Describe how Medicare providers and suppliers are reimbursed for the 

items and services they furnish. 

• Identify when Medicare is the secondary payer. 

• Recognize incentive payments. 

• Describe the Medicare Physician Fee Schedule. 

• Identify notices you may use or receive from Medicare. 

• Describe the other health insurance plans beneficiaries may be enrolled 

in. 

Chapter 4 – Medicare Payment Policies 

• Determine Medicare covered services. 

• Identify incident to services. 

• Determine the services that are not covered by Medicare. 

 

Chapter 5 – Evaluation and Management Services 

• Describe the two common sets of codes that are currently in use and the 

new classification system that will be used beginning on October 1, 2013. 

• Identify the seven general principles of documentation. 

• Identify the seven components that define the levels of evaluation and 

management services. 

02 Instructions for Facilitators 3
Chapter 6 – Protecting the Medicare Trust Fund 

• Identify the goal of the Medicare Integrity Program. 

• Describe the medical review process. 

• Determine the two types of coverage determinations. 

• Define Federal health care fraud. 

• Define program abuse. 

• Identify the potential legal actions that may be imposed if a provider, 

supplier, or health care organization has committed health care fraud and 

program abuse. 

Chapter 7 – Inquiries, Overpayments, and Fee-for-Service Appeals 

• Describe how providers and suppliers can find answers to inquiries. 

• Identify the reasons overpayments are often paid. 

• Identify the five levels of the fee-for-service appeals process. 

• Define a reopening. 

Let’s Review Section 

At the end of each chapter is a “Let’s Review” Section that facilitators may use to 

review the information that was covered and to generate discussion among the 

learners. The correct answer to each review question is provided. 

Post-Assessment 

After conducting the course, ask learners to complete the appropriate 

Post-Assessment, Word File(s) labeled “06 Chapter 1 Pre Post Assessment” – 

“12 Chapter 7 Pre Post Assessment.” The purpose of the Post-Assessment is 

to determine learners’ knowledge of Medicare after attending the course. 

Please make copies of completed Post-Assessment answer sheets for your 

locked, confidential file and mail originals to: 

Ann Palmer 

Centers for Medicare & Medicaid Services 

7500 Security Boulevard, Mail Stop C4-13-07 

 Baltimore, MD 21244 

Evaluations 

After each course has been conducted, please encourage learners to complete 

the Course Evaluation, Word file labeled “14 Course Evaluation.” This important 

tool is used to measure how well learners received the Medicare Resident, 

Practicing Physician, and Other Health Care Professional Training Program. 

Please make copies of the Course Evaluations completed by learners for your 

locked, confidential file and mail originals to: 

Ann Palmer 

Centers for Medicare & Medicaid Services 

7500 Security Boulevard, Mail Stop C4-13-07 

 Baltimore, MD 21244 

4 02 Instructions for Facilitators 
After you have conducted the course, please complete the Medicare Resident, 

Practicing Physician, and Other Health Care Professional Training Facilitator’s 

Kit Evaluation. This evaluation can be found on the MLN Product Ordering Page, 

which can be accessed by visiting http://www.cms.hhs.gov/MLNGenInfo on the 

CMS website. On this web page, scroll down to "Related Links Inside CMS" and 

select "MLN Product Ordering Page." 

Feedback received from learners and facilitators is very valuable to CMS. It 

assists in ensuring that our training materials and the Medicare Resident, 

Practicing Physician, and Other Health Care Professional Training Program meet 

the needs of facilitators and health care professionals. 

Questions 

If you have questions about the Medicare Resident, Practicing Physician, and 

Other Health Care Professional Training Program, please e-mail them to 

Residenttraining@cms.hhs.gov. 

02 Instructions for Facilitators 5
Preparing to Deliver the Course 

Checklist

Facilitators should have the following materials available on the day(s) the course 

will be conducted: 

√ 3-Hour Medicare Program Training Module 

√ Facilitator’s Guide

√ Medicare Resident, Practicing Physician, and Other Health Care 

 Professional Training: An Introduction Video 

√ Educational Products 

o Six weeks prior to the scheduled date of course, facilitators should 

order the Medicare Physician Guide: A Resource for Residents, 

Practicing Physicians, and Other Health Care Professionals for 

each learner from the MLN. To place your order, visit the MLN 

Product Ordering Page, which can accessed by visiting 

http://www.cms.hhs.gov/MLNGenInfo. On this web page, scroll 

down to "Related Links Inside CMS" and select "MLN Product 

Ordering Page." 

√ Slide Hand Outs 

 √ Pre- and Post-Assessments 

 √ Course Evaluations 

√ Reference Information (Hand Outs) 

√ Sign-In Sheets 

√ Markers and Highlighters 

√ Personal Computer 

√ Projector and Projection Screen 

√ Flipchart Stand and Paper 

√ Pencils and Pens 

Errata Sheets 

Errata sheets assist in ensuring that the Medicare Resident, Practicing Physician, 

and Other Health Care Professional Training Program course contains the most 

up-to-date information. When corrections or changes are identified, an errata 

sheet for the Medicare Physician Guide and Facilitator's Guide will be posted at 

http:www.cms.hhs.gov/MLNProducts/MPUB/list.asp on the CMS website. On this 

web page, under "Select From The Following Options," enter the title of the 

publication to be taken to the errata sheet link. Facilitators can also sign up to be 

notified when errata sheets are posted by subscribing to the Resident Training 

listserv. To subscribe to the listserv, visit https://list.nih.gov on the Web. 

Instructional Strategy

Facilitators may choose to present all chapters of the training module or tailor 

their own course by choosing the chapters that best meet the needs of learners. 

The training module is based on information found in the Medicare Physician 

Guide. 

6 02 Instructions for Facilitators 
Facilitators may also show learners the Medicare Resident, Practicing Physician, 

and Other Health Care Professional Training: An Introduction video. The video 

features Valerie Haugen, director of the Division of Provider Information Planning 

and Development at CMS, who presents information and resources that will 

assist physicians and other health care professionals in navigating the Medicare 

Program. 

Estimated Delivery Times 

Below are the estimated delivery times for each chapter of the training module. 

Note that delivery times may vary depending on: 

• Pace of the facilitator; 

• Course information presented; and 

• Number and complexity of learners’ questions. 

TITLE APPROXIMATE 

DELIVERY TIME

Chapter 1 Introduction to the Medicare 

Program

30 minutes 

Chapter 2 Becoming a Medicare Provider or 

Supplier 

35 minutes 

Chapter 3 Medicare Reimbursement 20 minutes 

Chapter 4 Medicare Payment Policies 15 minutes 

Chapter 5 Evaluation and Management 

Services 

45 minutes 

Chapter 6 Protecting the Medicare Trust Fund 15 minutes 

Chapter 7 Inquiries, Overpayments, and Feefor-Service Appeals 

20 minutes 

02 Instructions for Facilitators 7
Customizing and Printing the Promotional Flyer 

• Open the PowerPoint file labeled “03 Promotional Flyer.” 

• Place the cursor at “Insert Name of Organization” located at the top of the 

flyer and enter the name of your organization. 

• Place the cursor after “Date,” “Time,” “Place,” “Local Point of Contact,” and 

“Telephone Number” located at the bottom of the flyer and enter course 

and contact information. 

• Select FILE | PRINT. In the “Copies” section of the Print dialog box, enter 

the number of flyers you will need and select OK. Optional: Print one 

copy of the flyer and make additional copies using a copy machine. 

• Select FILE | SAVE. 

• Select FILE | CLOSE. 

• Notify learners about the upcoming course by posting the promotional 

flyers. 

8 02 Instructions for Facilitators 
Customizing and Printing the Sign-In Sheet 

• Open the Word file labeled “04 Program Sign In Sheet.” 

• Place the cursor at “Insert Name of Organization” located at the top of the 

sheet and enter the name of your organization. 

• Place the cursor at “Insert Date of Course” located at the top of the sheet 

and enter the date the course will be conducted. 

• Select FILE | PRINT. In the “Copies” section of the Print dialog box, enter 

the required number of Sign-In Sheets you will need based on the 

expected number of learners and select OK. Optional: Print one copy of 

the Sign-In Sheet and make additional copies using a copy machine. 

• Select FILE | SAVE. 

• Select FILE | CLOSE. 

• Please make copies of completed Sign-In Sheets for your locked, 

confidential file and mail original Sign-In Sheets to: 

Ann Palmer 

Centers for Medicare & Medicaid Services 

7500 Security Boulevard, Mail Stop C4-13-07 

Baltimore, MD 21244 

02 Instructions for Facilitators 9
 Customizing the 3-Hour Medicare Program Training Module 

• Open the PowerPoint file labeled “05 3 Hour Medicare Program Training 

Module.” 

• Select VIEW | HEADER and FOOTER from the menu bar. 

• Select the “Notes and Handouts” tab from the “Header and Footer” dialog 

box and check the following boxes: 

o Date and time; 

o Fixed; 

o Header; 

o Page number; and 

o Footer. 

• In the header section, place the cursor at “Name of Organization" and 

enter the name of your organization. 

• In the footer section, place the cursor at “Date of Course” and enter the 

date the course will be conducted. 

• Select “Apply to All.” 

• Select FILE | SAVE. 

• Select FILE | CLOSE. 

10 02 Instructions for Facilitators 
Customizing and Printing the Pre- and Post-Assessments 

• Each chapter of the training module has a separate Pre- and PostAssessment package. Learners should receive the corresponding 

package, depending on which chapter(s) of the training module you will be 

presenting. Open the appropriate Pre- and Post-Assessment Word file(s) 

labeled “06 Chapter 1 Pre Post Assessment” – “12 Chapter 7 Pre Post 

Assessment.” 

• Select VIEW | HEADER and FOOTER from the menu bar. Place the 

cursor at “Insert Name of Organization” in the header section and enter 

the name of your organization. Place the cursor at “Insert Date of Course” 

and enter the date the course will be conducted. 

• Select FILE | PRINT from menu bar. In the “Copies” section of the Print 

dialog box, enter the required number of Pre- and Post-Assessments 

based on the expected number of learners and select OK. Optional: Print 

one copy of each Pre- and Post-Assessment file and make additional 

copies using a copy machine. 

• Select FILE | SAVE. 

• Select FILE | CLOSE. 

• Please make copies of completed Pre- and Post-Assessment answer 

sheets for your locked, confidential file and mail original answer sheets to: 

 Ann Palmer 

 Centers for Medicare & Medicaid Services 

 7500 Security Boulevard, Mail Stop C4-13-07 

 Baltimore, MD 21244 

02 Instructions for Facilitators 11
12 02 Instructions for Facilitators 

Preparing the Request for a Centers for a 

Medicare & Medicaid Services-Led In-Person Course 

• If you would like to request a CMS Regional Office (RO)-led in-person 

Medicare Resident, Practicing Physician, and Other Health Care 

Professional Training Program course, open the file labeled “16 Request 

for Course.” 

• Select FILE | PRINT. 

• Select FILE | CLOSE. 

• In the table on page 2, circle the number that you believe best represents 

the importance of each chapter as it relates to the needs of the learners. 

Count the number of 2s and 3s that you circled. Add up the time required 

to present the chapters that you circled. Enter this information on page 3. 

• Ensure that the total time for the chapters you have selected does not exceed 

the time available for learners to attend the course. 

• See page 3 for instructions regarding where to mail or fax the request to 

your CMS RO. 

Please note that resource constraints may limit a RO’s ability to conduct inperson courses. 
Date:

Time: 

Place:

Local Point of Contact:

Telephone Number:

The Medicare 

Resident, Practicing Physician, and Other 

Health Care Professional Training Program 

is coming to 

[Insert Name of Organization] 

 This course offers residents, physicians, 

 and other health care professionals

 an overview of the Medicare Program

 Date: 

 Time: 

 Place: 

 Local Point of Contact: 

 Telephone Number: 

 The developers of this program have no conflicts of interests disclose. 

 

 03 Promotional Flyer 
04 Program Sign-In Sheet

MEDICARE RESIDENT, PRACTICING PHYSICIAN, AND

OTHER HEALTH CARE PROFESSIONAL TRAINING PROGRAM

SIGN-IN SHEET

[Insert Name of Organization]

[Insert Date of Course]

NAME (Please print) DEPARTMENT TELEPHONE # POSITION

 Student

 Resident

 New Physician

 Fellow

 Other (please specify) 

___________________

 Student

 Resident

 New Physician

 Fellow

 Other (please specify) 

____________________

 Student

 Resident

 New Physician

 Fellow

 Other (please specify) 

____________________

 Student

 Resident

 New Physician

 Fellow

 Other (please specify) 

____________________

 Student

 Resident

 New Physician

 Fellow

 Other (please specify) 

____________________

 Student

 Resident

 New Physician

 Fellow

 Other (please specify) 

____________________

 Student

 Resident

 New Physician

 Fellow

 Other (please specify) 

____________________

FACILITATORS: Please make copies of completed Sign-In Sheets for your locked, confidential file 

and mail original Sign-In Sheets to:

Ann Palmer

Centers for Medicare & Medicaid Services

7500 Security Boulevard, Mail Stop C4-13-07

Baltimore, MD 21244
Medicare Resident, Practicing 

Physician, and Other Health Care 

Professional Training Program
Medicare Resident, Practicing 

Physician, and Other Health Care 

Professional Training Program
Medicare Resident, Practicing 

Physician, and Other Health Care 

Professional Training Program
Medicare Resident, Practicing

Physician, and Other Health Care 

Professional Training Program 
Medicare Resident, Practicing

Physician, and Other Health Care 

Professional Training Program
Medicare Resident, Practicing

Physician, and Other Health Care 

Professional Training Program
Medicare Resident, Practicing 

Physician, and Other Health Care 

Professional Training Program
Pre-Assessment

8
CHAPTER 1

INTRODUCTION TO THE 

MEDICARE PROGRAM
The Medicare Program

• Largest health insurance program

• Over 1 billion claims annually

• Over 44 million individuals entitled

10
Identifying Beneficiaries

11

• Health insurance card contains

– Name

– Sex

– Medicare Health Insurance Claim number

– Date of entitlement
Introduction to the 

Medicare Program

• 4 parts

– Part A, hospital insurance

– Part B, medical insurance

– Part C, Medicare Advantage

– Part D, prescription drug plan

12
Part A

Hospital Insurance

• Inpatient hospital care

• Inpatient care in a Skilled Nursing Facility 

following covered hospital stay

• Some home health care

• Hospice care

13
Part A Eligibility

• Individuals age 65 years and older

– Insured 

– Not insured 

14
Part A Eligibility

• Individuals under age 65 with certain 

disabilities

• Individuals with End-Stage Renal Disease 

15
Part B

Medical Insurance

Physician and 

practitioner services

Home health care

Ambulance services

Clinical laboratory and

diagnostic services

Surgical supplies

Durable medical

equipment, prosthetics, 

orthotics, and supplies

Hospital outpatient

services

16
Part B Eligibility

• All individuals eligible for premium-free 

Part A are eligible to enroll

17
Part C 

Medicare Advantage

• Contract with CMS to furnish or arrange for 

provision of health care services to 

beneficiaries who

– Are entitled to Part A and enrolled in Part B

– Permanently reside in service area of Plan

– Elect to enroll in Medicare Advantage Plan

18
Part D

Prescription Drug Plans

• All who elect to enroll are covered 

• Individuals with limited resources may 

qualify for help paying for prescription drug 

costs 

19
Organizations That

Impact Medicare

• Social Security Administration

• Office of Inspector General

• Quality Improvement Organizations

• State Health Insurance Assistance Program

20
Let's Review

• What are Medicare’s 4 parts?

• Which Medicare beneficiaries are eligible 

to enroll in Medicare Advantage?

21
CHAPTER 2

BECOMING A MEDICARE 

PROVIDER OR SUPPLIER
Part A Providers and Suppliers

Inpatient Rehabilitation

Facilities

Long Term Care

Hospitals 

Rural Health Clinics

Skilled Nursing

Facilities

Critical Access Hospitals

Federally Qualified 

Health Centers

Home Health Agencies

Hospice

Hospitals (acute care

inpatient)
Part B Providers and Suppliers

Ambulances service

suppliers

Ambulatory Surgical

Centers 

Comprehensive Outpatient Rehabilitation

Facilities

End-Stage Renal

Disease Facilities

Home Health Agencies

Hospitals (outpatient)

Mass immunization

roster billers

Other non-physician

practitioners

Physicians

Skilled Nursing 

Facilities (outpatient)
Medicare Physicians

Must be legally authorized to practice by 

State

• Chiropractors

• Doctors of dental surgery or dental 

medicine

• Doctors of medicine and osteopathy

• Doctors of optometry

• Doctors of podiatry or surgical chiropody
Interns and Residents

• Participate in approved Graduate Medical 

Education programs 

• Not in approved programs, but authorized

to practice only in hospital setting

– Also includes interns, residents, and 

fellows in programs approved for purposes 

of direct Graduate Medical Education and 

Indirect Medical Education payments 
Teaching Physicians

• Involve residents in care of their patients

• Present during all critical or key portions of 

procedure 

• Immediately available to furnish services 

during entire service
Practitioners

Anesthesiologist

assistant

Certified nurse midwife

Clinical nurse specialist

Certified registered

nurse anesthetist

Clinical psychologist

Clinical social worker

Nurse practitioner

Physician assistant

Registered dietician

or nutrition

professional

Legally authorized to practice by State and 

otherwise meet Medicare requirements
Enrolling in Medicare

• Obtain National Provider Identifier 

• Complete Medicare Enrollment Application

29
Enrolling in Medicare

• Include with Medicare Enrollment 

Application

– Form CMS-588

– CMS Standard Electronic Data Interchange 

Enrollment Form

– Form CMS-460 (optional)

– State medical license

– Occupational or business license

– Certificate of Use

30
Participating Provider/Supplier

• Accepts assignment

• 1 year participation period

31
Participating Provider/

Supplier Benefits

• Higher Medicare Physician Fee Schedule

allowances

• Limiting charge provisions not applicable

• Included in Physician and Other Healthcare

Professional Directory

32
Nonparticipating 

Provider/Supplier

• May accept assignment of claims on claimby-claim basis 

• May not submit charges for nonassigned 

claims in excess of limiting charge amount

• May collect up to the limiting charge amount

33
Limiting Charge Example

MPFS Allowed Amount for 

Procedure “X”

Nonparticipating Provider/

Supplier Allowed Amount 

for Procedure “X”

Limiting Charge for 

Procedure “X”

Beneficiary Coinsurance 

and Limiting Charge Portion

Due to Provider/Supplier

$200.00

$190.00

$218.50

$ 66.50

34
Payment Amounts Example

35

Participating 

Provider/

Supplier

Nonparticipating

Provider/Supplier

Who Accepts

Assignment

Nonparticipating 

Provider/Supplier 

Who Does Not 

Accept Assignment

Submitted $125.00 $125.00 $109.25

Amount

MPFS Allowed $100.00 $ 95.00 $ 95.00

Amount

80 Percent of $ 80.00 $ 76.00 $ 76.00

MPFS Allowed 

Amount

Beneficiary $ 20.00 $ 19.00 $ 33.25

Coinsurance

Total Payment $100.00 $ 95.00 $109.25 ($95.00 x 

To Provider/ 1.15 limiting charge)

Supplier
Cultural Competency

• Addressing a patient’s social and cultural 

background assists in delivering high 

quality, effective health care
Let's Review

• What are the steps that must be taken in 

order to enroll in and obtain 

reimbursement from Medicare?

• What are the benefits of becoming a 

Medicare participating provider or 

supplier?
CHAPTER 3

MEDICARE REIMBURSEMENT
Medicare Claims

• Must submit claims for services 

• Cannot charge for completing or filing 

claim

• File on or before December 31 of calendar 

year following the year in which the 

services were furnished

• Services furnished in last quarter of year 

considered furnished in following year

39
Exceptions to 

Mandatory Filing

• Certain secondary payer claims 

• Services furnished outside the U.S.

• Services initially paid by third-party insurers

• Claims for unusual or excluded services

• Claims when provider/supplier opted out, 

excluded, or debarred 

40
Electronic Claims

• Claims must be submitted electronically, 

except in limited situations, using 

– Electronic media claims

– Electronic billing software vendor or 

clearinghouse

– Billing agent

– Medicare’s free billing software

41
Deductible, Coinsurance, 

and Copayment

• Deductible – amount beneficiary must pay 

before Medicare begins to pay

• Coinsurance – percentage of covered 

charges beneficiary may pay after meeting 

deductible

• Copayment – amount beneficiary pays for 

each medical service

42
Medicare Secondary Payer

• Must determine whether Medicare is the 

primary or secondary payer prior to 

submitting a claim

• Coordination of Benefits Contractor –

provides assistance to providers and 

suppliers

43
Incentive Payments 

• Health Professional Shortage Area 

Incentive Payment

• Physician Quality Reporting Initiative 

Incentive Payment 

44
Medicare Physician 

Fee Schedule

• Basis for payment of physician services 

under Medicare Part B 

• 3 components

– Relative Value Units

– Conversion Factor

– Geographic Practice Cost Indices

45
Medicare Notices

• Advance Beneficiary Notice

• Certificate of Medical Necessity and 

Durable Medical Equipment Medicare 

Administrative Contractor Information 

Forms

• Remittance Advice

• Medicare Summary Notice

46
Other Health Insurance Plans

• Medicare Advantage

• Medicaid

• Medigap

47
Let's Review

• What is a Health Professional Shortage 

Area incentive payment?

• What is the Advance Beneficiary Notice?

48
CHAPTER 4

MEDICARE PAYMENT POLICIES
Medicare Covered Services

Services and supplies must be medically

reasonable and necessary

– Proper and needed for diagnosis or 

treatment of medical condition

– Furnished for diagnosis, direct care, and 

treatment of medical condition

– Meet standards of good medical practice

– Not mainly for convenience

50
Part A Inpatient 

Hospital Services

Bed and board

Nursing and related

services

Use of hospital or Critical

Access Hospital facilities

Medical social services

Drugs, biologicals, 

supplies, appliances, 

and equipment

Diagnostic or therapeutic

services

Medical or surgical

services furnished by

interns or residents in

training

Transportation services

51
Part B Services

Surgery, consultations,

office visits, and

institutional calls

Services, supplies, 

and outpatient 

hospital services 

furnished incident

to physician services

Outpatient physical,

occupational, and

speech-language

pathology services

Diagnostic tests

Ambulance services

Preventive services

52
Incident to Provision

• Commonly furnished in physicians’ offices or 

clinics

• Furnished by physician or auxiliary personnel 

under direct personal supervision of physician

• Furnished without charge or included in 

physician’s bill

• Integral, although incidental, part physician’s 

professional service
Services not Covered 

by Medicare 

• Excluded services

• Services considered not medically necessary 

• Services denied as bundled or included in 

basic allowance of another service

Medicare also does not pay for claims rejected

as unprocessable
Let's Review

• What are medically reasonable and 

necessary services and supplies?

• What services are not covered by 

Medicare?

55
CHAPTER 5

EVALUATION AND 

MANAGEMENT SERVICES
• Diagnostic or International Classification 

of Diseases, 9th Edition, Clinical 

Modification Codes

• Procedural or Current Procedural 

Terminology Codes

Currently Used 

Common Sets of Codes

57
• Visits

• Consultations 

Evaluation and 

Management Services

58
• Compliance date for implementation of 

new classification system –

October 1, 2013 

• Two parts:

– ICD-10-CM

– ICD-10-PCS 

ICD-10-CM/PCS

59
Medical Record 

Documentation

• Records pertinent facts, findings, and 

observations about patient’s health history

• Facilitates 

– Evaluating and planning treatment and monitoring 

treatment and health of patient

– Communication and continuity of care

– Claims review and payment

– Utilization review and quality of care evaluations

– Collection of data 

60
7 General Principles 

of Documentation

1. Medical record should be complete and 

legible

61
7 General Principles 

of Documentation

2. Each encounter should include

– Reason for encounter and relevant history, 

physical examination findings, and prior test 

results

– Assessment, clinical impression, or 

diagnosis

– Plan for care

– Date and legible identity of observer

62
7 General Principles 

of Documentation

3. Rationale for ordering diagnostic tests and 

ancillary services should be easily inferred 

if not documented

4. Past and present diagnoses accessible to 

treating and/or consulting physician

5. Appropriate health risk factors identified

63
7 General Principles 

of Documentation

6. Patient’s progress, response to and 

changes in treatment, and revision of 

diagnosis documented

7. CPT and ICD codes reported on health 

insurance claim form or billing statement 

supported by documentation in medical 

record

64
Levels of Evaluation and 

Management Services

History

Examination

Medical decision 

making

Counseling

Coordination of care

Nature of presenting

problem

Time

65
3 Key Components 

Procedure History Examination Medical Decision 

Code Making

99201 Problem Focused Problem Focused Straightforward

99202 Expanded Expanded Straightforward

Problem Focused Problem Focused

99203 Detailed Detailed Low Complexity

99204 Comprehensive Comprehensive Moderate Complexity

99205 Comprehensive Comprehensive High Complexity

CPT only copyright 2008 American Medical Association. All rights reserved.

66
History

4 LEVELS

Problem Focused

Expanded Problem

Focused

Detailed

Comprehensive

ELEMENTS

Chief complaint

History of present

illness

Review of systems

Past, family, and/or

social history

67
History

68

HPI ROS PFSH Level of History

Brief N/A N/A Problem Focused

(1 – 3 elements)

Brief Problem Pertinent N/A Expanded Problem 

(1 – 3 elements) Focused

Extended Extended Pertinent Detailed

(4 or more elements)

Extended Complete Complete Comprehensive

(4 or more elements)

Elements: ROS: PFHS areas:

location, quality, constitutional, eyes, ears past history

severity, duration, nose, mouth, throat, family history

timing, context, cardiovascular, respiratory, social history

modifying factors, gastrointestinal, gastroassociated signs urinary, musculoskeletal

and symptoms integumentary, neurological, psychiatric, 

endocrine, hematologic/

lymphatic, allergic/

immunologic
History

69

Procedure History Examination Medical Decision 

Code Making

99201 Problem Focused Problem Focused Straightforward

99202 Expanded Expanded Straightforward

Problem Focused Problem Focused

99203 Detailed Detailed Low Complexity

99204 Comprehensive Comprehensive Moderate Complexity

99205 Comprehensive Comprehensive High Complexity

CPT only copyright 2008 American Medical Association. All rights reserved.
Examination

• 4 types

– Problem Focused

– Expanded Problem Focused

– Detailed

– Comprehensive

• General multi-system or single organ 

system

70
General Multi-System 

Examination 

71

Level of Examination Perform and Document

Problem Focused 1– 5 elements identified by a bullet in 1 or more 

organ system(s) or body area(s)

Expanded Problem At least 6 elements identified by a bullet in 1 or

Focused more organ system(s) or body area(s)

Detailed At least 2 elements identified by a bullet from

at least 6 organ systems or body areas or at

least 12 elements identified by a bullet in 2 or

more organ systems or body areas

Comprehensive All elements identified by a bullet in at least

9 organ systems or body areas; for each 

system/area, at least 2 elements identified by a

bullet 
General Multi-System

Examination

• Elements of examination

72
General Multi-System 

Examination 

73

Level of Examination Perform and Document

Problem Focused 1– 5 elements identified by a bullet in 1 or more 

organ system(s) or body area(s)

Expanded Problem At least 6 elements identified by a bullet in 1 or

Focused more organ system(s) or body area(s)

Detailed At least 2 elements identified by a bullet from

at least 6 organ systems or body areas or at

least 12 elements identified by a bullet in 2 or

more organ systems or body areas

Comprehensive All elements identified by a bullet in at least

9 organ systems or body areas; for each 

system/area, at least 2 elements identified by a

bullet 
Single Organ System 

Examination 

74

Level of Examination Perform and Document

Problem Focused 1 – 5 elements identified by bullet in box with

either shaded or unshaded border

Expanded Problem At least 6 elements identified by bullet in box

Focused with either shaded or unshaded border

Detailed At least 12 elements identified by bullet in box 

with either shaded or unshaded border (except

eye and psychiatric examinations)

Comprehensive Perform all elements identified by bullet in box 

with either shaded or unshaded border; 

document every element in each box with

shaded border and at least 1 element in box

with unshaded border
New Patient Visit 

75

Procedure History Examination Medical Decision 

Code Making

99201 Problem Focused Problem Focused Straightforward

99202 Expanded Expanded Straightforward

Problem Focused Problem Focused

99203 Detailed Detailed Low Complexity

99204 Comprehensive Comprehensive Moderate Complexity

99205 Comprehensive Comprehensive High Complexity

CPT only copyright 2008 American Medical Association. All rights reserved.
Medical Decision Making

• Straightforward

• Low complexity

• Moderate complexity

• High complexity

76
Medical Decision Making

77

Number of Amount and/or Risk of Type of Medical

Diagnoses/ Complexity of Complications, Decision Making

Management Data to be Morbidity, and/or

Options Reviewed Mortality

Minimal Minimal or None Minimal Straightforward

Limited Limited Low Low Complexity

Multiple Moderate Moderate Moderate

Complexity

Extensive Extensive High High Complexity
Medical Decision Making

78

Number of Amount and/or Risk of Type of Medical

Diagnoses/ Complexity of Complications, Decision Making

Management Data to be Morbidity, and/or 

Options Reviewed Mortality

Minimal Minimal or None Minimal Straightforward

Limited Limited Low Low Complexity

Multiple Moderate Moderate Moderate

Complexity

Extensive Extensive High High Complexity
Medical Decision Making

79

Number of Amount and/or Risk of Type of Medical

Diagnoses/ Complexity of Complications, Decision Making

Management Data to be Morbidity, and/or 

Options Reviewed Mortality

Minimal Minimal or None Minimal Straightforward

Limited Limited Low Low Complexity

Multiple Moderate Moderate Moderate

Complexity

Extensive Extensive High High Complexity
New Patient Visit 

80

Procedure History Examination Medical Decision 

Code Making

99201 Problem Focused Problem Focused Straightforward

99202 Expanded Expanded Straightforward

Problem Focused Problem Focused

99203 Detailed Detailed Low Complexity

99204 Comprehensive Comprehensive Moderate Complexity

99205 Comprehensive Comprehensive High Complexity

CPT only copyright 2008 American Medical Association. All rights reserved.
Established Patient Visit

81

Procedure History Examination Medical Decision 

Code Making

99211 N/A N/A N/A

99212 Problem Focused Problem Focused Straightforward

99213 Expanded Problem Expanded Problem Low Complexity 

Focused Focused

99214 Detailed Detailed Moderate Complexity

99215 Comprehensive Comprehensive High Complexity

CPT only copyright 2008 American Medical Association. All rights reserved.
Let's Review

• What are the 7 components that define the 

levels of evaluation and management 

services?

• What is the compliance date for 

implementation of the International 

Classification of Diseases, 10th Edition, 

Clinical Modification/Procedure Coding 

System (ICD-10-CM/PCS)?

82
CHAPTER 6

PROTECTING THE 

MEDICARE TRUST FUND
Medical Review Program

• Analyze data

• Take action to prevent and/or address 

identified errors

• Publish local medical review policies

84
National Coverage 

Determination

• Sets forth extent to which Medicare covers 

specific services, procedures, or 

technologies on a national basis

85
Local Coverage Determination

• Developed to further define a National 

Coverage Determination or in absence of a 

specific National Coverage Determination

• Made at Contractor’s discretion to provide 

guidance to public and medical community 

within specified geographic area 

86
Deterring Health Care 

Fraud and Program Abuse

• Identify suspicious Medicare charges and 

activities

• Investigate and punish those who commit 

Medicare fraud and abuse

• Ensure money is returned to Medicare Trust 

Fund

87
Federal Health

Care Fraud 

• Intentional use of false statements or

fraudulent schemes to obtain payment for, or

to cause another person or entity to obtain

payment for, items or services payable

under a Federal health care program

88
Program Abuse 

• Intentional or unintentional 

• Directly or indirectly results in unnecessary

or increased costs to the Medicare Program

89
Potential Legal Actions

• Fine

• Prison sentence

• Temporary or permanent exclusion from 

Medicare and other health care programs

• Lose license

• Civil Monetary Penalties

90
Potential Legal Actions

• Deny individual’s or entity’s application for 

Medicare provider billing privileges

• Revoke provider’s billing privileges

• Suspend payment

91
Report Suspected

Fraud or Abuse

Office of Inspector General 

Department of Health and Human Services

ATTENTION: HOTLINE 

P. O. Box 23489

Washington, DC 20026

Telephone – (800) 447-8477

E-mail – HHSTips@oig.hhs.gov

Fax – (800) 223-8164

92
Let's Review

• What are the 2 types of coverage 

determinations that assist providers and 

suppliers in coding correctly and billing 

Medicare only for covered items and 

services?

• What is program abuse?

93
CHAPTER 7

INQUIRIES, OVERPAYMENTS, 

AND FEE-FOR-SERVICE APPEALS
Inquiries

• Submit by telephone or in writing

• Interactive Voice Response Services

95
Overpayments

• Funds that a provider, supplier, or 

beneficiary received in excess of amounts 

due and payable

96
5 Levels of FeeFor-Service Appeals

• First level – Redetermination by Medicare 

Contractor

• Second level – Reconsideration by 

Qualified Independent Contractor 

97
5 Levels of FeeFor-Service Appeals

• Third level – Hearing by Administrative Law 

Judge

• Fourth level – Appeals Council Review

• Fifth level – Judicial Review 

98
Reopening

• Remedial action to change a final 

determination or decision that resulted in an 

overpayment or an underpayment

• Allows correction of minor errors or 

omissions without initiating a formal appeal

99
Let's Review

• Under what circumstances are 

overpayments often paid?

• What are the 5 levels in the appeals 

process?

100
Post-Assessment 

Course Evaluation

Thank You 

for 

Your Feedback

101
MEDICARE RESIDENT, PRACTICING 

PHYSICIAN, AND OTHER HEALTH CARE 

PROFESSIONAL TRAINING PROGRAM

(Insert Name of Organization)

(Insert Date of Course)

06 Chapter 1 Pre Post Assessment 1

PRE-ASSESSMENT

CHAPTER 1

Directions

Complete the Pre-Assessment when directed by the course facilitator.

Mark your answers on the attached answer sheet. 

Please hand in your completed answer sheet prior to exiting today’s 

course.

1. Part C of the Medicare Program is:

A. Long term care insurance

B. Medicare Advantage

C. Disability insurance

D. Medical insurance

2. Medicare Part A is available to insured individuals age 65 or older, individuals 

under age 65 with certain disabilities, and individuals with End-Stage Renal 

Disease.

 A. True

 B. False

3. An example of a Part B service is inpatient hospital care.

A. True

 B. False
MEDICARE RESIDENT, PRACTICING 

PHYSICIAN, AND OTHER HEALTH CARE 

PROFESSIONAL TRAINING PROGRAM

(Insert Name of Organization)

(Insert Date of Course)

06 Chapter 1 Pre Post Assessment 2

PRE-ASSESSMENT ANSWER SHEET

CHAPTER 1

A B C D

1. 0 0 0 0

2. 0 0 0 0

3. 0 0 0 0

FACILITATORS:

Please make copies of completed Pre- and Post-Assessment answer 

sheets for your locked, confidential file and mail original answer 

sheets to:

Ann Palmer

Centers for Medicare & Medicaid Services

7500 Security Boulevard, Mail Stop C4-13-07

Baltimore, MD 21244
MEDICARE RESIDENT, PRACTICING 

PHYSICIAN, AND OTHER HEALTH CARE 

PROFESSIONAL TRAINING PROGRAM

(Insert Name of Organization)

(Insert Date of Course)

06 Chapter 1 Pre Post Assessment 3

POST-ASSESSMENT

CHAPTER 1

Directions

Complete the Post-Assessment when directed by the course facilitator.

Mark your answers on the attached answer sheet. 

Please hand in your completed answer sheet prior to exiting today’s 

course.

1. Part C of the Medicare Program is:

A. Long term care insurance

B. Medicare Advantage

C. Disability insurance

D. Medical insurance

2. Medicare Part A is available to insured individuals age 65 or older, individuals 

under age 65 with certain disabilities, and individuals with End-Stage Renal 

Disease.

 A. True

 B. False

3. An example of a Part B service is inpatient hospital care.

A. True

 B. False
MEDICARE RESIDENT, PRACTICING 

PHYSICIAN, AND OTHER HEALTH CARE 

PROFESSIONAL TRAINING PROGRAM

(Insert Name of Organization)

(Insert Date of Course)

06 Chapter 1 Pre Post Assessment 4

POST-ASSESSMENT ANSWER SHEET

CHAPTER 1

A B C D

1. 0 0 0 0

2. 0 0 0 0

3. 0 0 0 0

FACILITATORS:

Please make copies of completed Pre- and Post-Assessment answer 

sheets for your locked, confidential file and mail original answer 

sheets to:

Ann Palmer

Centers for Medicare & Medicaid Services

7500 Security Boulevard, Mail Stop C4-13-07

Baltimore, MD 21244
MEDICARE RESIDENT, PRACTICING 

PHYSICIAN, AND OTHER HEALTH CARE 

PROFESSIONAL TRAINING PROGRAM

(Insert Name of Organization)

(Insert Date of Course)

07 Chapter 2 Pre Post Assessment 1

PRE-ASSESSMENT

CHAPTER 2

Directions

Complete the Pre-Assessment when directed by the course facilitator.

Mark your answers on the attached answer sheet. 

Please hand in your completed answer sheet prior to exiting today’s 

course.

1. End-Stage Renal Disease facilities are an example of an entity that receives 

payment under Part A of the Medicare Program.

A. True

B. False

2. The National Provider Identifier is a unique identification number for health 

care providers that is a Health Insurance Portability and Accountability Act 

Administrative Simplification Standard.

A. True

B. False

3. Participating providers and suppliers are held to a limiting charge.

A. True

B. False
MEDICARE RESIDENT, PRACTICING 

PHYSICIAN, AND OTHER HEALTH CARE 

PROFESSIONAL TRAINING PROGRAM

(Insert Name of Organization)

(Insert Date of Course)

07 Chapter 2 Pre Post Assessment 2

PRE-ASSESSMENT ANSWER SHEET

CHAPTER 2

A B

1. 0 0

2. 0 0

3. 0 0

FACILITATORS:

Please make copies of completed Pre- and Post-Assessment answer 

sheets for your locked, confidential file and mail original answer sheets to:

Ann Palmer

Centers for Medicare & Medicaid Services

7500 Security Boulevard, Mail Stop C4-13-07

Baltimore, MD 21244
MEDICARE RESIDENT, PRACTICING 

PHYSICIAN, AND OTHER HEALTH CARE 

PROFESSIONAL TRAINING PROGRAM

(Insert Name of Organization)

(Insert Date of Course)

07 Chapter 2 Pre Post Assessment 3

POST-ASSESSMENT

CHAPTER 2

Directions

Complete the Post-Assessment when directed by the course facilitator.

Mark your answers on the attached answer sheet. 

Please hand in your completed answer sheet prior to exiting today’s 

course.

1. End-Stage Renal Disease facilities are an example of an entity that receives 

payment under Part A of the Medicare Program.

A. True

B. False

2. The National Provider Identifier is a unique identification number for health 

care providers that is a Health Insurance Portability and Accountability Act 

Administrative Simplification Standard.

A. True

B. False

3. Participating providers and suppliers are held to a limiting charge.

A. True

B. False
MEDICARE RESIDENT, PRACTICING 

PHYSICIAN, AND OTHER HEALTH CARE 

PROFESSIONAL TRAINING PROGRAM

(Insert Name of Organization)

(Insert Date of Course)

07 Chapter 2 Pre Post Assessment 4

POST-ASSESSMENT ANSWER SHEET

CHAPTER 2

A B

1. 0 0

2. 0 0

3. 0 0

FACILITATORS:

Please make copies of completed Pre- and Post-Assessment answer 

sheets for your locked, confidential file and mail original answer 

sheets to:

Ann Palmer

Centers for Medicare & Medicaid Services

7500 Security Boulevard, Mail Stop C4-13-07

Baltimore, MD 21244
MEDICARE RESIDENT, PRACTICING 

PHYSICIAN, AND OTHER HEALTH CARE 

PROFESSIONAL TRAINING PROGRAM

(Insert Name of Organization)

(Insert Date of Course)

08 Chapter 3 Pre Post Assessment 1

PRE-ASSESSMENT

CHAPTER 3

Directions

Complete the Pre-Assessment when directed by the course facilitator.

Mark your answers on the attached answer sheet. 

Please hand in your completed answer sheet prior to exiting today’s 

course.

1. Providers and suppliers must collect which of the following from the 

beneficiary:

A. Coinsurance

B. Unmet deductibles

C. Copayments

D. All of the above

2. Medigap is a health insurance policy that fills gaps in Original Medicare Plan 

coverage.

A. True

B. False

3. Health Professional Shortage Area Incentive Payments include both a 

professional and a technical component.

A. True

B. False
MEDICARE RESIDENT, PRACTICING 

PHYSICIAN, AND OTHER HEALTH CARE 

PROFESSIONAL TRAINING PROGRAM

(Insert Name of Organization)

(Insert Date of Course)

08 Chapter 3 Pre Post Assessment 2

PRE-ASSESSMENT ANSWER SHEET

CHAPTER 3

A B C D

1. 0 0 0 0

2. 0 0 0 0

3. 0 0 0 0

FACILITATORS:

Please make copies of completed Pre- and Post-Assessment answer 

sheets for your locked, confidential file and mail original answer 

sheets to:

Ann Palmer

Centers for Medicare & Medicaid Services

7500 Security Boulevard, Mail Stop C4-13-07

Baltimore, MD 21244
MEDICARE RESIDENT, PRACTICING 

PHYSICIAN, AND OTHER HEALTH CARE 

PROFESSIONAL TRAINING PROGRAM

(Insert Name of Organization)

(Insert Date of Course)

08 Chapter 3 Pre Post Assessment 3

POST-ASSESSMENT

CHAPTER 3

Directions

Complete the Post-Assessment when directed by the course facilitator.

Mark your answers on the attached answer sheet. 

Please hand in your completed answer sheet prior to exiting today’s

course.

1. Providers and suppliers must collect which of the following from the 

beneficiary:

A. Coinsurance

B. Unmet deductibles

C. Copayments

D. All of the above

2. Medigap is a health insurance policy that fills gaps in Original Medicare Plan 

coverage.

A. True

B. False

3. Health Professional Shortage Area Incentive Payments include both a 

professional and a technical component.

A. True

B. False
MEDICARE RESIDENT, PRACTICING 

PHYSICIAN, AND OTHER HEALTH CARE 

PROFESSIONAL TRAINING PROGRAM

(Insert Name of Organization)

(Insert Date of Course)

08 Chapter 3 Pre Post Assessment 4

POST-ASSESSMENT ANSWER SHEET

CHAPTER 3

A B C D

1. 0 0 0 0

2. 0 0 0 0

3. 0 0 0 0

FACILITATORS:

Please make copies of completed Pre- and Post-Assessment answer 

sheets for your locked, confidential file and mail original answer 

sheets to:

Ann Palmer

Centers for Medicare & Medicaid Services

7500 Security Boulevard, Mail Stop C4-13-07

Baltimore, MD 21244
MEDICARE RESIDENT, PRACTICING 

PHYSICIAN, AND OTHER HEALTH CARE 

PROFESSIONAL TRAINING PROGRAM

(Insert Name of Organization)

(Insert Date of Course)

09 Chapter 4 Pre Post Assessment 1

PRE-ASSESSMENT

CHAPTER 4

Directions

Complete the Pre-Assessment when directed by the course facilitator.

Mark your answers on the attached answer sheet. 

Please hand in your completed answer sheet prior to exiting today’s 

course.

1. Services or supplies are considered medically reasonable and necessary if 

they are mainly for the convenience of the beneficiary, provider, or supplier.

A. True

B. False

2. Services that are included in the basic allowance of another service are 

covered by Medicare.

A. True

B. False

3. One requirement for coverage of incident to services of a physician is that the 

services and supplies are commonly furnished without charge or included in the 

physician’s bill.

A. True

B. False
MEDICARE RESIDENT, PRACTICING 

PHYSICIAN, AND OTHER HEALTH CARE 

PROFESSIONAL TRAINING PROGRAM

(Insert Name of Organization)

(Insert Date of Course)

09 Chapter 4 Pre Post Assessment 2

PRE-ASSESSMENT ANSWER SHEET

CHAPTER 4

A B

1. 0 0

2. 0 0

3. 0 0

FACILITATORS:

Please make copies of completed Pre- and Post-Assessment answer 

sheets for your locked, confidential file and mail original answer 

sheets to:

Ann Palmer

Centers for Medicare & Medicaid Services

7500 Security Boulevard, Mail Stop C4-13-07

Baltimore, MD 21244
MEDICARE RESIDENT, PRACTICING 

PHYSICIAN, AND OTHER HEALTH CARE 

PROFESSIONAL TRAINING PROGRAM

(Insert Name of Organization)

(Insert Date of Course)

09 Chapter 4 Pre Post Assessment 3

POST-ASSESSMENT

CHAPTER 4

Directions

Complete the Post-Assessment when directed by the course facilitator.

Mark your answers on the attached answer sheet. 

Please hand in your completed answer sheet prior to exiting today’s 

course.

1. Services or supplies are considered medically reasonable and necessary if 

they are mainly for the convenience of the beneficiary, provider, or supplier.

A. True

B. False

2. Services that are included in the basic allowance of another service are 

covered by Medicare.

A. True

B. False

3. One requirement for coverage of incident to services of a physician is that the 

services and supplies are commonly furnished without charge or included in the 

physician’s bill.

A. True

B. False
MEDICARE RESIDENT, PRACTICING 

PHYSICIAN, AND OTHER HEALTH CARE 

PROFESSIONAL TRAINING PROGRAM

(Insert Name of Organization)

(Insert Date of Course)

09 Chapter 4 Pre Post Assessment 4

POST-ASSESSMENT ANSWER SHEET

CHAPTER 4

A B

1. 0 0

2. 0 0

3. 0 0

FACILITATORS:

Please make copies of completed Pre- and Post-Assessment answer 

sheets for your locked, confidential file and mail original answer 

sheets to:

Ann Palmer

Centers for Medicare & Medicaid Services

7500 Security Boulevard, Mail Stop C4-13-07

Baltimore, MD 21244
MEDICARE RESIDENT, PRACTICING 

PHYSICIAN, AND OTHER HEALTH CARE 

PROFESSIONAL TRAINING PROGRAM

(Insert Name of Organization)

(Insert Date of Course)

10 Chapter 5 Pre Post Assessment 1

PRE-ASSESSMENT

CHAPTER 5

Directions

Complete the Pre-Assessment when directed by the course facilitator.

Mark your answers on the attached answer sheet. 

Please hand in your completed answer sheet prior to exiting today’s 

course.

1. The physician must ensure that documentation reflects the services furnished 

and that the codes selected reflect those services.

A. True

B. False

2. The compliance date for implementation of the International Classification 

of Diseases, 10th Edition, Clinical Modification/Procedure Coding System 

(ICD-10-CM/PCS) is October 1, 2011.

A. True

B. False

3. Medical decision making refers to the complexity of establishing a diagnosis 

and/or selecting a management option.

A. True

B. False
MEDICARE RESIDENT, PRACTICING 

PHYSICIAN, AND OTHER HEALTH CARE 

PROFESSIONAL TRAINING PROGRAM

(Insert Name of Organization)

(Insert Date of Course)

10 Chapter 5 Pre Post Assessment 2

PRE-ASSESSMENT ANSWER SHEET

CHAPTER 5

A B

1. 0 0

2. 0 0

3. 0 0

FACILITATORS:

Please make copies of completed Pre- and Post-Assessment answer 

sheets for your locked, confidential file and mail original answer 

sheets to:

Ann Palmer

Centers for Medicare & Medicaid Services

7500 Security Boulevard, Mail Stop C4-13-07

Baltimore, MD 21244
MEDICARE RESIDENT, PRACTICING 

PHYSICIAN, AND OTHER HEALTH CARE 

PROFESSIONAL TRAINING PROGRAM

(Insert Name of Organization)

(Insert Date of Course)

10 Chapter 5 Pre Post Assessment 3

POST-ASSESSMENT

CHAPTER 5

Directions

Complete the Post-Assessment when directed by the course facilitator.

Mark your answers on the attached answer sheet. 

Please hand in your completed answer sheet prior to exiting today’s 

course.

1. The physician must ensure that documentation reflects the services furnished 

and that the codes selected reflect those services.

A. True

B. False

2. The compliance date for implementation of the International Classification 

of Diseases, 10th Edition, Clinical Modification/Procedure Coding System 

(ICD-10-CM/PCS) is October 1, 2011.

A. True

B. False

3. Medical decision making refers to the complexity of establishing a diagnosis 

and/or selecting a management option.

A. True

B. False
MEDICARE RESIDENT, PRACTICING 

PHYSICIAN, AND OTHER HEALTH CARE 

PROFESSIONAL TRAINING PROGRAM

(Insert Name of Organization)

(Insert Date of Course)

10 Chapter 5 Pre Post Assessment 4

POST-ASSESSMENT ANSWER SHEET

CHAPTER 5

A B

1. 0 0

2. 0 0

3. 0 0

FACILITATORS:

Please make copies of completed Pre- and Post-Assessment answer 

sheets for your locked, confidential file and mail original answer 

sheets to:

Ann Palmer

Centers for Medicare & Medicaid Services

7500 Security Boulevard, Mail Stop C4-13-07

Baltimore, MD 21244
MEDICARE RESIDENT, PRACTICING 

PHYSICIAN, AND OTHER HEALTH CARE 

PROFESSIONAL TRAINING PROGRAM

(Insert Name of Organization)

(Insert Date of Course)

11 Chapter 6 Pre Post Assessment 1

PRE-ASSESSMENT

CHAPTER 6

Directions

Complete the Pre-Assessment when directed by the course 

facilitator.

Mark your answers on the attached answer sheet. 

Please hand in your completed answer sheet prior to exiting today’s 

session.

1. Local Coverage Determinations are developed to further define a National 

Coverage Determination (NCD) or in the absence of a specific NCD.

A. True

B. False

2. Program abuse involves an individual’s or entity’s intentional use of false 

statements or fraudulent schemes to obtain payment for, or to cause another 

person or entity to obtain payment for, items or services payable under a Federal 

health care program.

A. True

B. False

3. Federal health care fraud, which may be intentional or unintentional, directly or 

indirectly results in unnecessary or increased costs to the Medicare Program.

A. True

B. False 
MEDICARE RESIDENT, PRACTICING 

PHYSICIAN, AND OTHER HEALTH CARE 

PROFESSIONAL TRAINING PROGRAM

(Insert Name of Organization)

(Insert Date of Course)

11 Chapter 6 Pre Post Assessment 2

PRE-ASSESSMENT ANSWER SHEET

CHAPTER 6

A B

1. 0 0

2. 0 0

3. 0 0

FACILITATORS:

Please make copies of completed Pre- and Post-Assessment answer 

sheets for your locked, confidential file and mail original answer 

sheets to:

Ann Palmer

Centers for Medicare & Medicaid Services

7500 Security Boulevard, Mail Stop C4-13-07

Baltimore, MD 21244
MEDICARE RESIDENT, PRACTICING 

PHYSICIAN, AND OTHER HEALTH CARE 

PROFESSIONAL TRAINING PROGRAM

(Insert Name of Organization)

(Insert Date of Course)

11 Chapter 6 Pre Post Assessment 3

POST-ASSESSMENT

CHAPTER 6

Directions

Complete the Post-Assessment when directed by the course 

facilitator.

Mark your answers on the attached answer sheet. 

Please hand in your completed answer sheet prior to exiting today’s 

session.

1. Local Coverage Determinations are developed to further define a National 

Coverage Determination (NCD) or in the absence of a specific NCD.

A. True

B. False

2. Program abuse involves an individual’s or entity’s intentional use of false 

statements or fraudulent schemes to obtain payment for, or to cause another 

person or entity to obtain payment for, items or services payable under a Federal 

health care program.

A. True

B. False

3. Federal health care fraud, which may be intentional or unintentional, directly or 

indirectly results in unnecessary or increased costs to the Medicare Program.

A. True

B. False 
MEDICARE RESIDENT, PRACTICING 

PHYSICIAN, AND OTHER HEALTH CARE 

PROFESSIONAL TRAINING PROGRAM

(Insert Name of Organization)

(Insert Date of Course)

11 Chapter 6 Pre Post Assessment 4

POST-ASSESSMENT ANSWER SHEET

CHAPTER 6

A B

1. 0 0

2. 0 0

3. 0 0

FACILITATORS:

Please make copies of completed Pre- and Post-Assessment answer 

sheets for your locked, confidential file and mail original answer 

sheets to:

Ann Palmer

Centers for Medicare & Medicaid Services

7500 Security Boulevard, Mail Stop C4-13-07

Baltimore, MD 21244
MEDICARE RESIDENT, PRACTICING 

PHYSICIAN, AND OTHER HEALTH CARE 

PROFESSIONAL TRAINING PROGRAM

(Insert Name of Organization)

(Insert Date of Course)

12 Chapter 7 Pre Post Assessment 1

PRE-ASSESSMENT

CHAPTER 7

Directions

Complete the Pre-Assessment when directed by the course facilitator.

Mark your answers on the attached answer sheet. 

Please hand in your completed answer sheet prior to exiting today’s 

course.

1. Medicare Contractors do not accept inquiries via telephone.

A. True

B. False

2. An example of an overpayment is when an incorrect payee is paid.

A. True

B. False

3. There are three levels of fee-for-service appeals.

A. True

B. False
MEDICARE RESIDENT, PRACTICING 

PHYSICIAN, AND OTHER HEALTH CARE 

PROFESSIONAL TRAINING PROGRAM

(Insert Name of Organization)

(Insert Date of Course)

12 Chapter 7 Pre Post Assessment 2

PRE-ASSESSMENT ANSWER SHEET

CHAPTER 7

A B

1. 0 0

2. 0 0

3. 0 0

FACILITATORS:

Please make copies of completed Pre- and Post-Assessment answer 

sheets for your locked, confidential file and mail original answer sheets to:

Ann Palmer

Centers for Medicare & Medicaid Services

7500 Security Boulevard, Mail Stop C4-13-07

Baltimore, MD 21244
MEDICARE RESIDENT, PRACTICING 

PHYSICIAN, AND OTHER HEALTH CARE 

PROFESSIONAL TRAINING PROGRAM

(Insert Name of Organization)

(Insert Date of Course)

12 Chapter 7 Pre Post Assessment 3

POST-ASSESSMENT

CHAPTER 7

Directions

Complete the Post-Assessment when directed by the course facilitator.

Mark your answers on the attached answer sheet. 

Please hand in your completed answer sheet prior to exiting today’s 

course.

1. Medicare Contractors do not accept inquiries via telephone.

A. True

B. False

2. An example of an overpayment is when an incorrect payee is paid.

A. True

B. False

3. There are three levels of fee-for-service appeals.

A. True

B. False
MEDICARE RESIDENT, PRACTICING 

PHYSICIAN, AND OTHER HEALTH CARE 

PROFESSIONAL TRAINING PROGRAM

(Insert Name of Organization)

(Insert Date of Course)

12 Chapter 7 Pre Post Assessment 4

POST-ASSESSMENT ANSWER SHEET

CHAPTER 7

A B

1. 0 0

2. 0 0

3. 0 0

FACILITATORS:

Please make copies of completed Pre- and Post-Assessment answer 

sheets for your locked, confidential file and mail original answer sheets to:

Ann Palmer

Centers for Medicare & Medicaid Services

7500 Security Boulevard, Mail Stop C4-13-07

Baltimore, MD 21244
13 Master Answer Keys 1

MEDICARE RESIDENT, PRACTICING PHYSICIAN, AND

OTHER HEALTH CARE PROFESSIONAL TRAINING PROGRAM

MASTER ANSWER KEYS

CHAPTER 1

QUESTION CORRECT ANSWER

1. Part C of the Medicare Program is:

A. Long term care insurance

B. Medicare Advantage

C. Disability insurance

D. Medical insurance 

B

2. Medicare Part A is available to insured individuals 

age 65 or older, individuals under age 65 with certain 

disabilities, and individuals with End-Stage Renal 

Disease.

 A. True

 B. False

A

3. An example of a Part B service is inpatient hospital 

care.

A. True

 B. False

B
2 13 Master Answer Keys

Master Answer Keys

CHAPTER 2

QUESTION CORRECT ANSWER

1. End-Stage Renal Disease facilities are an 

example of an entity that receives payment under 

Part A of the Medicare Program.

A. True

B. False

B

2. The National Provider Identifier is a unique 

identification number for health care providers that 

is a Health Insurance Portability and 

Accountability Act Administrative Simplification 

Standard.

A. True

B. False

A

3. Participating providers and suppliers are held to 

a limiting charge.

A. True

B. False

B
13 Master Answer Keys 3

Master Answer Keys

CHAPTER 3

QUESTION CORRECT ANSWER

1. Providers and suppliers must collect which of the 

following from the beneficiary:

A. Coinsurance

B. Unmet deductibles

C. Copayments

D. All of the above

D

2. Medigap is a health insurance policy that fills 

gaps in Original Medicare Plan coverage.

A. True

B. False

A

3. Health Professional Shortage Area Incentive 

Payments include both a professional and a 

technical component.

A. True

B. False

B
4 13 Master Answer Keys

Master Answer Keys

CHAPTER 4

QUESTION CORRECT ANSWER

1. Services or supplies are considered medically 

reasonable and necessary if they are mainly for the 

convenience of the beneficiary, provider, or 

supplier.

A. True

B. False

B

2. Services that are included in the basic allowance 

of another service are covered by Medicare.

A. True

B. False

B

3. One requirement for coverage of incident to 

services of a physician is that the services and 

supplies are commonly furnished without charge or 

included in the physician’s bill.

A. True

B. False

A
13 Master Answer Keys 5

Master Answer Keys

CHAPTER 5

QUESTION CORRECT ANSWER

1. The physician must ensure that documentation 

reflects the services furnished and that the codes 

selected reflect those services.

A. True

B. False

A

2. The compliance date for implementation of the 

International Classification of Diseases, 10th Edition, 

Clinical Modification/Procedure Coding System 

(ICD-10-CM/PCS) is October 1, 2011.

A. True

B. False

B

3. Medical decision making refers to the complexity 

of establishing a diagnosis and/or selecting a 

management option.

A. True

B. False

A
6 13 Master Answer Keys

Master Answer Keys

CHAPTER 6

QUESTION CORRECT ANSWER

1. Local Coverage Determinations are developed 

to further define a National Coverage Determination 

(NCD) or in the absence of a specific NCD.

A. True

B. False

A

2. Program abuse involves an individual’s or entity’s 

intentional use of false statements or fraudulent 

schemes to obtain payment for, or to cause another 

person or entity to obtain payment for, items or 

services payable under a Federal health care 

program.

A. True

B. False

B

3. Federal health care fraud, which may be 

intentional or unintentional, directly or indirectly 

results in unnecessary or increased costs to the 

Medicare Program.

A. True

B. False

B
13 Master Answer Keys 7

Master Answer Keys

CHAPTER 7

QUESTION CORRECT ANSWER

1. Medicare Contractors do not accept inquiries via 

telephone.

A. True

B. False

B

2. An example of an overpayment is when an 

incorrect payee is paid.

A. True

B. False

A

3. There are three levels of fee-for-service 

appeals.

A. True

B. False

B
14 Course Evaluation 1

This evaluation tool should not be modified.

MEDICARE RESIDENT, PRACTICING PHYSICIAN, AND 

OTHER HEALTH CARE PROFESSIONAL TRAINING PROGRAM

COURSE EVALUATION

Date of Training Program:____________ Name of Organization:__________________

EXCELLENT VERY

GOOD

GOOD FAIR POOR

FACILITY

Rate the location 

of the facility

5 4 3 2 1

Rate the comfort 

of the meeting 

room, including 

seating and 

temperature

5 4 3 2 1

PROGRAM

How well did the 

training program 

meet your 

expectation?

5 4 3 2 1

Rate the length 

of the training 

program

5 4 3 2 1

Rate the 

program 

schedule, 

including start 

time, breaks, and 

end time

5 4 3 2 1

Rate the 

relevance of the 

program to your 

current or future 

work

5 4 3 2 1

Rate your 

knowledge of the 

subject matter 

before the 

training program

5 4 3 2 1

Rate your 

knowledge of the 

subject matter 

after the training 

program

5 4 3 2 1

Rate how well 

the program 

objectives were 

met

5 4 3 2 1
14 Course Evaluation 2

EXCELLENT VERY 

GOOD

GOOD FAIR POOR

INSTRUCTOR

Rate the 

instructor’s 

subject matter 

knowledge 

and ability to 

answer 

questions

5 4 3 2 1

Rate the 

instructor’s ability 

to present the 

information in an 

understandable 

way

5 4 3 2 1

Rate the 

instructor’s 

effectiveness as 

a communicator

5 4 3 2 1

Rate the 

preparedness of 

the instructor

5 4 3 2 1

MATERIALS

How well did the 

training materials 

relate to your 

skill level?

5 4 3 2 1

How effective or 

useful are the 

training 

materials?

How useful are 

the audiovisual 

aids and hand 

outs in 

communicating 

the training 

information?

How effective 

are the hand 

outs as a 

resource?
14 Course Evaluation 3

1. What methods of delivery do you prefer to receive training? (Please check all 

that apply.)

___Computer or Web-Based Training

___In-Person Training

___Print

___CD-ROM

___DVD

___Audio CD

___Web Streaming/Webinar

___Podcast

___Teleconference Call/Telephone

___Radio/Satellite Radio

___Video Conferencing

___Fax

___Cable Television/Network Television

___Direct Mail from CMS

2. Please provide us with your comments or suggestions regarding any aspect 

of the Medicare Resident, Practicing Physician, and Other Health Care 

Professional Training Program.

________________________________________________________________

________________________________________________________________

________________________________________________________________

________________________________________________________________

________________________________________________________________

Thank you for your feedback. We will use your input to improve our Medicare 

training courses and products.

Facilitators:

Please make copies of completed evaluations for your locked, confidential 

file and mail original evaluations to:

Ann Palmer

Centers for Medicare & Medicaid Services

7500 Security Boulevard, Mail Stop C4-13-07

Baltimore, MD 21244
15 Reference 1

REFERENCE

SECTION
15 Reference 2

GLOSSARY

A

Advance Beneficiary Notice 

A written notice that a provider or supplier gives to a beneficiary under certain 

circumstances (e.g., lack of medical necessity) before items or services are furnished to 

advise him or her that specified items or services may not be covered by Medicare. 

Appeal

Complaint a beneficiary, provider of services, or supplier can make if he or she 

disagrees with a Medicare coverage or payment decision. 

Assignment

When a provider or supplier is paid the Medicare allowed amount as payment in full for 

his or her services. 

B

Beneficiary

Individual eligible to receive Medicare or Medicaid payment and/or services.

C

Carrier

Centers for Medicare & Medicaid Services Contactor that determines reasonable 

charges, accuracy, and coverage for Medicare Part B services and processes Part B 

claims and payments (see Medicare Administrative Contractor).

Centers for Medicare & Medicaid Services 

The Federal agency that administers and oversees the Medicare Program and a portion 

of the Medicaid Program. It also regulates laboratory testing and surveys and certifies 

Rural Health Clinics, Federally Qualified Health Centers, Critical Access Hospitals, 

nursing homes, health care agencies, intermediate care facilities for the mentally 

retarded, and hospitals.

Claim

A request for payment of benefits or services received by a beneficiary. 

Code of Federal Regulations 

Official compilation of Federal rules and requirements.
15 Reference 3

Coinsurance

Under the Original Medicare Plan or a Private Fee-for-Service Plan, a percentage of 

covered charges that the Medicare beneficiary may pay after he or she has met the 

applicable deductible. 

Coordination of Benefits

The process that determines the respective responsibilities of two or more payers that 

have some financial responsibility for a medical claim.

Copayment

In some Medicare health plans, the amount that is paid by the beneficiary for each 

medical service.

Cost Report

Report required from providers on an annual basis in order to make a proper 

determination of amounts payable under the Medicare Program.

Covered Service

A reasonable and necessary service furnished to Medicare or Medicaid beneficiaries 

and reimbursable to the provider, supplier, or beneficiary.

D

Deductible

Amount a beneficiary must pay before Medicare begins to pay for covered services and 

supplies.

Durable Medical Equipment 

Medical equipment ordered by a physician or, if Medicare allows, a nurse practitioner, 

physician assistant or clinical nurse specialist for use in the home. The item must be 

reusable (e.g., walkers, wheelchairs, or hospital beds).

Durable Medical Equipment Medicare Administrative Contractor

A private company that contracts with Medicare to pay bills for durable medical 

equipment.

F

Fiscal Intermediary

Centers for Medicare & Medicaid Services Contractor that processes claims for services 

covered under Medicare Part A and most types of claims for services covered under 

Medicare Part B (see Medicare Administrative Contractor).
15 Reference 4

H

Health Care Fraud

Generally involves an individual’s or entity’s intentional use of false statements or 

fraudulent schemes (such as kickbacks) to obtain payment for, or to cause another

individual to obtain payment for, items or services payable under a Federal health care 

program. 

Health Professional Shortage Area Incentive Payment

A 10 percent payment made to physicians (including psychiatrists) who furnish care in 

an area that is designated as a geographic-based, primary medical care Health 

Professional Shortage Area (HPSA) and psychiatrists who furnish care in an area that is 

designated as a geographic-based mental health HPSA for outpatient professional 

services furnished to a Medicare beneficiary. 

I

Incentive Reward Program

A program that encourages the reporting of information regarding individuals or entities 

that commit fraud or abuse and could result in sanctions under any Federal health care 

program.

Incident to Provision

Services and supplies must meet four requirements to be covered under the incident to 

provision: services are commonly furnished in physicians’ offices or clinics; services are 

furnished by the physician or auxiliary personnel under the direct personal supervision 

of a physician; services are commonly furnished without charge or included in the 

physician’s bill; and services or supplies are an integral, although incidental, part of the 

physician’s professional service.

L

Local Coverage Determination

A coverage decision developed by Medicare Contractors at their own discretion to 

further define a National Coverage Determination (NCD) or in the absence of a specific 

NCD to provide guidance to the public and the medical community within a specified 

geographic area. 

M

Medicaid

A cooperative venture funded by Federal and State governments that pays for medical 

assistance for certain individuals and families with low incomes and limited resources.
15 Reference 5

Medically Necessary

Services or supplies that are proper and needed for the diagnosis or treatment of the 

beneficiary’s medical condition; furnished for the diagnosis, direct care, and treatment of 

the beneficiary’s medical condition; meet the standards of good medical practice; and 

are not mainly for the convenience of the beneficiary, provider, or supplier.

Medicare Administrative Contractor

All Medicare work performed by Fiscal Intermediaries, Carriers, and Durable Medical 

Equipment Carriers will be replaced by these Centers for Medicare & Medicaid Services 

Contractors by 2011, as mandated in Section 911 of the Medicare Prescription Drug, 

Improvement, and Modernization Act of 2003. 

Medicare Advantage; Part C of the Medicare Program

A program through which organizations that contract with the Centers for Medicare & 

Medicaid Services furnish or arrange for the provision of health care services to 

Medicare beneficiaries (with the exception of individuals with End-Stage Renal Disease

who are generally excluded from enrolling in Medicare Advantage [MA] Plans) who are 

entitled to Part A and enrolled in Part B, permanently reside in the service area of the 

MA Plan, and elect to enroll in a MA Plan.

Medicare Economic Index 

A measure of inflation faced by physicians with respect to their practice costs and 

general wage levels. 

Medicare Physician Fee Schedule

The basis for which Medicare Part B pays for physician services. It lists the more than 

7,000 covered services and their payment rates. 

Medicare Summary Notice

Notice that beneficiaries receive on a monthly basis that lists all services or supplies 

that were billed to Medicare.

Medigap

A health insurance policy sold by private insurance companies to fill gaps in Original 

Medicare Plan coverage.

N

National Coverage Determination

A coverage policy that sets forth the extent to which Medicare will cover specific 

services, procedures, or technologies on a national basis.
15 Reference 6

National Provider Identifier

Unique identification number for health care providers that that is a Health Insurance 

Portability and Accountability Act (HIPAA) Administrative Standard. Covered health care 

providers and all health plans and health care clearinghouses must use this 

identification number in the administrative and financial transactions adopted under 

HIPAA.

O

Office of Inspector General 

Organization that protects the integrity of Department of Health and Human Services 

programs and the health and welfare of beneficiaries of those programs through a 

nationwide network of audits, investigations, inspections, and other mission-related 

functions.

Overpayment

Funds that a provider, supplier, or beneficiary has received in excess of amounts due 

and payable under Medicare statutes and regulations.

P

Part A of the Medicare Program

Hospital insurance that helps pay for inpatient hospital care, inpatient care in a Skilled 

Nursing Facility following a covered hospital stay, some home health care, and hospice 

care.

Part B of the Medicare Program

Medical insurance that helps pay for medically necessary services furnished by 

physicians in a variety of medical settings; home health care for individuals who do not 

have Part A; ambulance services; clinical laboratory and diagnostic services; surgical 

supplies; durable medical equipment, prosthetics, orthotics, and supplies; hospital 

outpatient services; and services furnished by practitioners with limited licensing.

Part C of the Medicare Program; Medicare Advantage

A program through which organizations that contract with the Centers for Medicare & 

Medicaid Services furnish or arrange for the provision of health care services to 

Medicare beneficiaries (with the exception of individuals with End-Stage Renal Disease) 

who are entitled to Part A and enrolled in Part B, permanently reside in the service area 

of the Medicare Advantage (MA) Plan, and elect to enroll in a MA Plan.

Part D of the Medicare Program; Prescription Drug Plan

Plan that provides prescription drug coverage to all beneficiaries who elect to enroll in a 

prescription drug plan or Medicare Advantage Plan that includes Part D.
15 Reference 7

Participating Provider or Supplier

A provider or supplier who agrees to participate in Part B and accept assignment of 

Medicare benefits for all covered services for all Medicare beneficiaries. 

Physician 

Defined by Medicare to include chiropractors, doctors of dental surgery or dental 

medicine, doctors of medicine and doctors of osteopathy, doctors of optometry, or 

doctors of podiatry or surgical chiropody. In addition, the physician must be legally 

authorized to practice by a State in which he or she performs this function.

Practitioner 

Defined by Medicare as any of the following to the extent that an individual is legally 

authorized to practice by the State and otherwise meets Medicare requirements: 

anesthesiologist assistant, certified nurse midwife, clinical nurse specialist, certified 

registered nurse anesthetist, clinical psychologist, clinical social worker, nurse 

practitioner, physician assistant, or registered dietician or nutrition professional.

Prescription Drug Plan; Part D of the Medicare Program

Plan that provides prescription drug coverage to all beneficiaries who elect to enroll in a 

prescription drug plan or Medicare Advantage Plan that includes Part D.

Program Abuse

In general, may be intentional or unintentional and directly or indirectly results in 

unnecessary or increased costs to the Medicare Program. 

Prospective Payment System 

Method of reimbursement in which Medicare payment is made based on a 

predetermined, fixed amount.

Q

Quality Improvement Organization

Private, mostly not-for-profit organizations that are staffed by professionals who are

trained to review medical care, help beneficiaries with complaints about quality of care, 

and implement improvements in the quality of care. 

R

Remittance Advice

A notice of payments and adjustments that is sent to the provider, supplier, or biller.
15 Reference 8

S

Social Security Act (the Act)

Public Law 74-271 that was enacted on August 14, 1935, with subsequent 

amendments. 

Social Security Administration

The Federal agency that determines eligibility for Medicare benefits and enrolls 

individuals in Part A and/or Part B and the Federal Black Lung Benefit Program. 

Swing Bed 

Bed that a small rural hospital can use for either Skilled Nursing Facility or hospital 

acute-level care on an as-needed basis if the hospital has obtained approval from the 

Department of Health and Human Services.

U.S. Department of Health and Human Services 

The Federal department that administers many health and welfare programs for citizens 

of the U.S. and is the parent agency of the Centers for Medicare & Medicaid Services.
15 Reference 9

ACRONYMS

AA Anesthesiologist Assistant

ABN Advance Beneficiary Notice

AEP Annual Coordinated Election Period

AIC Amount in Controversy

ALJ Administrative Law Judge

ASC Ambulatory Surgical Center

CAH Critical Access Hospital

CF Conversion Factor 

CFR Code of Federal Regulations

CMN Certificate of Medical Necessity

CMP Civil Monetary Penalties 

CMS Centers for Medicare & Medicaid Services

CNM Certified Nurse Midwife

CNS Certified Nurse Specialist

COB Coordination of Benefits

COBC Coordination of Benefits Contractor

CP Clinical Psychologist

CPI-U Consumer Price Index for All Urban Consumers

CPT Current Procedural Terminology

CRNA Certified Registered Nurse Anesthetist
15 Reference 10

CSR Customer Service Representative

CSW Clinical Social Worker

CWF Common Working File

DIF Durable Medical Equipment Medicare Administrative 

Contractor Information Form

DME Durable Medical Equipment

DME MAC Durable Medical Equipment Medicare Administrative

Contractor

DMEPOS Durable Medical Equipment, Prosthetics, Orthotics, and 

Supplies

DOJ Department of Justice

EDI Electronic Data Interchange

EFT Electronic Funds Transfer 

E/M Evaluation and Management

EMC Electronic Media Claims

ESRD End-Stage Renal Disease

FI Fiscal Intermediary

FICA Federal Insurance Contributions Act 

FPL Federal Poverty Level

GHP Group Health Plan

GME Graduate Medical Education

GPCI Geographic Practice Cost Indices

HHS Department of Health and Human Services
15 Reference 11

HIC Health Insurance Claim 

HIPAA Health Insurance Portability and Accountability Act

HPSA Health Professional Shortage Area

ICD-9-CM International Classification of Diseases, 9th Edition, Clinical 

Modification

ICD-10-CM/PCS International Classification of Diseases, 10th Edition, Clinical 

Modification/Procedure Coding System

IEP Initial Enrollment Period

IVR Interactive Voice Response

LCD Local Coverage Determination

LEIE List of Excluded Individuals/Entities

MA Medicare Advantage

MAC Medicare Administrative Contractor

MEI Medicare Economic Index

MLN Medicare Learning Network

MPFS Medicare Physician Fee Schedule

MRN Medicare Redetermination Notice

MSA Medical Savings Account

MSN Medicare Summary Notice

MSP Medicare Secondary Payer

NCD National Coverage Determination

NP Nurse Practitioner

NPI National Provider Identifier
15 Reference 12

NPP Non-Physician Practitioner

OEP Open Enrollment Period

OIG Office of Inspector General

OT Occupational Therapy

PA Physician Assistant

PACE Program for All-Inclusive Care for the Elderly 

PDP Prescription Drug Plan

PE Practice Expense

PECOS Provider Enrollment, Chain and Ownership System 

PEN Parenteral and Enteral Nutrition

PFFS Private Fee-for-Service

PPO Preferred Provider Organization

PPS Prospective Payment System

PQRI Physician Quality Reporting Initiative

PT Physical Therapy

QC Quarters of Coverage

QDWI Qualified Disabled and Working Individual

QIC Qualified Independent Contractor

QIO Quality Improvement Organization

QMB Qualified Medicare Beneficiary

RA Remittance Advice

RO Regional Offices
15 Reference 13

RRB Railroad Retirement Board

RVU Relative Value Unit

SA State Agency

SEP Special Enrollment Period

SGR Sustainable Growth Rate

SHIP State Health Insurance Program

SLP Speech-Language Pathology

SNF Skilled Nursing Facility 

SSA Social Security Administration

SSN Social Security Number

UMWA United Mine Workers of America

WC Workers’ Compensation
15 Reference 14

CONTACT INFORMATION

CENTERS FOR MEDICARE & MEDICAID SERVICES

About CMS

http://www.cms.hhs.gov/home/aboutcms.asp

Administrative Simplification Compliance Act Self Assessment

http://www.cms.hhs.gov/ElectronicBillingEDITrans/05_ASCASelfAssessment.asp

All Fee-for-Service Providers

http://www.cms.hhs.gov/center/provider.asp

Ambulance Services Center

http://www.cms.hhs.gov/center/ambulance.asp

Anesthesiologists Center

http://www.cms.hhs.gov/center/anesth.asp

Beneficiary Notices Initiative (Advance Beneficiary Notice)

http://www.cms.hhs.gov/BNI/01_overview.asp

CMS Forms

http://www.cms.hhs.gov/CMSForms/CMSForms/list.asp

Coordination of Benefits – General Information

http://www.cms.hhs.gov/COBGeneralInformation

Documentation Guidelines for E & M Services

http://www.cms.hhs.gov/MLNEdWebGuide/25_EMDOC.asp

Durable Medical Equipment Center

http://www.cms.hhs.gov/center/dme.asp

Electronic Billing & EDI Transactions

http://www.cms.hhs.gov/ElectronicBillingEDITrans

Electronic Billing & EDI Transactions

Administrative Simplification Compliance Act Self Assessment

http://www.cms.hhs.gov/ElectronicBillingEDITrans/05_ASCASelfAssessment.asp
15 Reference 15

Electronic Billing & EDI Transactions

Health Care Payment and Remittance Advice

http://www.cms.hhs.gov/ElectronicBillingEDITrans/11_Remittance.asp

HPSA/PSA (Physician Bonuses)

http://www.cms.hhs.gov/HPSAPSAPhysicianBonuses

Health Care Payment and Remittance Advice

http://www.cms.hhs.gov/ElectronicBillingEDITrans/11_Remittance.asp

Health Insurance Portability and Accountability Act – General Information 

http://www.cms.hhs.gov/HIPAAGenInfo 

Health Plans – General Information (Medicare Advantage)

http://www.cms.hhs.gov/HealthPlansGenInfo

Home Health Agency Center

http://www.cms.hhs.gov/center/hha.asp

Hospice Center

http://www.cms.hhs.gov/center/hospice.asp

Hospital Center

http://www.cms.hhs.gov/center/hospital.asp 

ICD-9-CM

http://www.cms.hhs.gov/ICD9ProviderDiagnosticCodes/01_overview.asp

ICD-10-CM/PCS

http://www.cms.hhs.gov/ICD10

Manuals

http://www.cms.hhs.gov/Manuals

Medicaid Program – Contact Information

http://www.cms.hhs.gov/apps/firststep/content/medicaid-contact.html

Medicaid Program – General Information

http://www.cms.hhs.gov/MedicaidGenInfo

Medicare (beneficiaries)

http://www.medicare.gov

(800) 633-4227
15 Reference 16

Medicare Contracting Reform

http://www.cms.hhs.gov/MedicareContractingReform

Medicare Coordination of Benefits Contractor

(800) 999-1118

Medicare Coverage Center

http://www.cms.hhs.gov/center/coverage.asp 

Medicare Coverage Database

http://www.cms.hhs.gov/mcd/search.asp

Medicare Coverage Determination Process

http://www.cms.hhs.gov/DeterminationProcess/01_Overview.asp

Medicare Fee-for-Service Provider Enrollment Contact List

http://www.cms.hhs.gov/MedicareProviderSupEnroll/downloads/contact_list.pdf

Medicare Fee-for-Service Provider Listservs

http://www.cms.hhs.gov/prospmedicarefeesvcpmtgen/downloads/Provider_Listservs.pdf

Medicare Learning Network 

http://www.cms.hhs.gov/MLNGenInfo

Medicare Managed Care Appeals & Grievances

http://www.cms.hhs.gov/MMCAG

Medicare Prescription Drug Appeals & Grievances

http://www.cms.hhs.gov/MedPrescriptDrugApplGriev/

Medicare Program – General Information

http://www.cms.hhs.gov/MedicareGenInfo

Medicare Provider-Supplier Enrollment 

http://www.cms.hhs.gov/MedicareProviderSupEnroll

Medicare Summary Notices

http://www.cms.hhs.gov/MSN/01_overview.asp

Medicare Supplement Health Insurance (Medigap)

http://www.cms.hhs.gov/Medigap

National Plan and Provider Enumeration System

https://nppes.cms.hhs.gov
15 Reference 17

National Provider Identifier Standard

http://www.cms.hhs.gov/NationalProvIdentStand 

Open Door Forums 

http://www.cms.hhs.gov/OpenDoorForums 

Original Medicare (Fee-for-Service) Appeals

http://www.cms.hhs.gov/OrgMedFFSAppeals

Pharmacist Center

http://www.cms.hhs.gov/center/pharmacist.asp

Physician Center

http://www.cms.hhs.gov/center/physician.asp 

Physician Fee Schedule 

http://www.cms.hhs.gov/PhysicianFeeSched/01_overview.asp

Physician Fee Schedule Look-Up 

http://www.cms.hhs.gov/PFSlookup

Physician Quality Reporting Initiative

http://www.cms.hhs.gov/PQRI

Physicians Regulatory Issues Team

http://www.cms.hhs.gov/PRIT

Practice Administration Center

http://www.cms.hhs.gov/center/practice.asp

Practicing Physicians Advisory Council 

http://www.cms.hhs.gov/FACA/03_ppac.asp

Prescription Drug Coverage – General Information 

http://www.cms.hhs.gov/PrescriptionDrugCovGenIn 

Private Fee-for-Service Plans

http://www.cms.hhs.gov/PrivateFeeforServicePlans

Provider Call Center Toll-Free Numbers Directory 

http://www.cms.hhs.gov/MLNGenInfo/30_contactus.asp 

Newsroom Center 

http://www.cms.hhs.gov/center/press.asp
15 Reference 18

Quality Improvement Organizations 

http://www.cms.hhs.gov/QualityImprovementOrgs/01_Overview.asp

Quarterly Provider Updates

http://www.cms.hhs.gov/QuarterlyProviderUpdates

Regulations & Guidance

http://www.cms.hhs.gov/home/regsguidance.asp 

Resident Training Listserv

https://list.nih.gov

State Health Insurance and Assistance Programs

http://www.cms.hhs.gov/Partnerships/10_SHIPS.asp

Survey & Certification – General Information

http://www.cms.hhs.gov/SurveyCertificationGenInfo/03_ContactInformation.asp

Therapy Services

http://www.cms.hhs.gov/TherapyServices

OTHER ORGANIZATIONS

American Medical Association 

Bookstore (Current Procedural Terminology and Healthcare Common Procedure 

Coding System publications)

http://www.amapress.org

(800) 621-8335

American Medical Association 

Current Procedural Terminology Information

http://www.ama-assn.org/ama/pub/physician-resources/solutions-managing-yourpractice/coding-billing-insurance/cpt.shtml

Federal Financial Institutions Examination Council (census tracts)

http://www.ffiec.gov/Geocode/default.aspx

National Uniform Billing Committee

http://www.nubc.org/guide.html

Railroad Medicare Part B Office

(800) 833-4455 
15 Reference 19

United Mine Workers of America

Electronic Medical Claims Submission Information

(888) 865-5290 

U.S. Department of Health and Human Services

Administration on Aging

http://www.aoa.gov

U.S. Department of Health and Human Services

Health Resources and Services Administration

http://www.hrsa.gov

U.S. Department of Health and Human Services

Health Resources and Services Administration

Shortage Areas by State and County

http://www.hpsafind.hrsa.gov

U.S. Department of Health and Human Services 

Office of Inspector General

http://www.oig.hhs.gov

U.S. Department of Health and Human Services 

Office of Inspector General

List of Excluded Individuals/Entities

http://www.oig.hhs.gov/fraud/exclusions/exclusions_list.asp

U.S. Department of Health and Human Services 

Office of Inspector General 

National Hotline

(800) 447-8477

U.S. Department of Health and Human Services

Office of Medicare Hearings and Appeals 

http://www.hhs.gov/omha

U.S. Department of Health and Human Services 

Office of Minority Health

Cultural Competency Continuing Education Programs

http://thinkculturalhealth.org

U.S. General Services Administration 

Excluded Parties List System 

http://www.epls.gov
15 Reference 20

U.S. Government Printing Office 

Code of Federal Regulations 

http://www.gpoaccess.gov/cfr/index.html

U.S. Government Printing Office 

U.S. Government Bookstore (CMS-1500 claim forms and ICD-9-CM CD-ROM)

http://bookstore.gpo.gov

(866) 512-1800 

U.S. Social Security Administration

http://www.ssa.gov 

(800) 772-1213
15 Reference 21

1995 DOCUMENTATION GUIDELINES

FOR EVALUATION & MANAGEMENT SERVICES

I. INTRODUCTION

WHAT IS DOCUMENTATION AND WHY IS IT IMPORTANT?

Medical record documentation is required to record pertinent facts, findings, and 

observations about an individual's health history including past and present illnesses, 

examinations, tests, treatments, and outcomes. The medical record chronologically 

documents the care of the patient and is an important element contributing to high 

quality care. The medical record facilitates:

the ability of the physician and other healthcare professionals to evaluate and 

plan the patient’s immediate treatment, and to monitor his/her healthcare over 

time;

communication and continuity of care among physicians and other healthcare 

professionals involved in the patient's care;

accurate and timely claims review and payment;

appropriate utilization review and quality of care evaluations; and

collection of data that may be useful for research and education.

An appropriately documented medical record can reduce many of the "hassles" 

associated with claims processing and may serve as a legal document to verify the care 

provided, if necessary.

WHAT DO PAYERS WANT AND WHY?

Because payers have a contractual obligation to enrollees, they may require reasonable 

documentation that services are consistent with the insurance coverage provided. They 

may request information to validate:

the site of service;

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the medical necessity and appropriateness of the diagnostic and/or therapeutic 

services provided; and/or

that services provided have been accurately reported.

II. GENERAL PRINCIPLES OF MEDICAL RECORD DOCUMENTATION

The principles of documentation listed below are applicable to all types of medical and 

surgical services in all settings. For Evaluation and Management (E/M) services, the 

nature and amount of physician work and documentation varies by type of service, 

place of service and the patient's status. The general principles listed below may be 

modified to account for these variable circumstances in providing E/M services.

1. The medical record should be complete and legible.

2. The documentation of each patient encounter should include:

reason for the encounter and relevant history, physical examination findings, 

and prior diagnostic test results;

assessment, clinical impression, or diagnosis;

plan for care; and

date and legible identity of the observer.

3. If not documented, the rationale for ordering diagnostic and other ancillary 

services should be easily inferred.

4. Past and present diagnoses should be accessible to the treating and/or 

consulting physician.

5. Appropriate health risk factors should be identified.

6. The patient's progress, response to and changes in treatment, and revision of 

diagnosis should be documented.

7. The CPT and ICD-9-CM codes reported on the health insurance claim form or 

billing statement should be supported by the documentation in the medical record.

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II. DOCUMENTATION OF E/M SERVICES

This publication provides definitions and documentation guidelines for the three key 

components of E/M services and for visits which consist predominately of counseling or 

coordination of care. The three key components--history, examination, and medical 

decision making--appear in the descriptors for office and other outpatient services, 

hospital observation services, hospital inpatient services, consultations, emergency 

department services, nursing facility services, domiciliary care services, and home 

services. While some of the text of CPT has been repeated in this publication, the 

reader should refer to CPT for the complete descriptors for E/M services and 

instructions for selecting a level of service. Documentation guidelines are identified 

by the symbol • DG.

The descriptors for the levels of E/M services recognize seven components which are 

used in defining the levels of E/M services. These components are:

history;

examination;

medical decision making;

counseling;

coordination of care;

nature of presenting problem; and

time.

The first three of these components (i.e., history, examination and medical decision 

making) are the key components in selecting the level of E/M services. An exception to 

this rule is the case of visits which consist predominantly of counseling or coordination 

of care; for these services time is the key or controlling factor to qualify for a particular 

level of E/M service. 

For certain groups of patients, the recorded information may vary slightly from that 

described here. Specifically, the medical records of infants, children, adolescents and 

pregnant women may have additional or modified information recorded in each history 

and examination area.

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As an example, newborn records may include under history of the present illness (HPI) 

the details of mother’s pregnancy and the infant's status at birth; social history will focus 

on family structure; family history will focus on congenital anomalies and hereditary 

disorders in the family. In addition, information on growth and development and/or 

nutrition will be recorded. Although not specifically defined in these documentation 

guidelines, these patient group variations on history and examination are appropriate.

A. DOCUMENTATION OF HISTORY

The levels of E/M services are based on four types of history (Problem Focused, 

Expanded Problem Focused, Detailed, and Comprehensive). Each type of history 

includes some or all of the following elements:

Chief complaint (CC);

History of present illness (HPI);

Review of systems (ROS); and

Past, family and/or social history (PFSH).

The extent of history of present illness, review of systems, and past, family and/or social 

history that is obtained and documented is dependent upon clinical judgment and the 

nature of the presenting problem(s).

The chart below shows the progression of the elements required for each type of 

history. To qualify for a given type of history, all three elements in the table must be 

met. (A chief complaint is indicated at all levels.)

History of 

Present Illness 

(HPI)

Review of Systems 

(ROS)

Past, Family, 

and/or Social 

History (PFSH)

Type of History

Brief N/A N/A Problem 

Focused

Brief Problem Pertinent N/A Expanded 

Problem 

Focused

Extended Extended Pertinent Detailed

Extended Complete Complete Comprehensive

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DG: The CC, ROS and PFSH may be listed as separate elements of history, or 

they may be included in the description of the history of the present illness.

DG: A ROS and/or a PFSH obtained during an earlier encounter does not need 

to be re-recorded if there is evidence that the physician reviewed and updated 

the previous information. This may occur when a physician updates his/her own 

record or in an institutional setting or group practice where many physicians use 

a common record. The review and update may be documented by:

o describing any new ROS and/or PFSH information or noting there has been 

no change in the information; and

o noting the date and location of the earlier ROS and/or PFSH.

DG: The ROS and/or PFSH may be recorded by ancillary staff or on a form 

completed by the patient. To document that the physician reviewed the 

information, there must be a notation supplementing or confirming the 

information recorded by others.

DG: If the physician is unable to obtain a history from the patient or other source, 

the record should describe the patient's condition or other circumstance which 

precludes obtaining a history.

Definitions and specific documentation guidelines for each of the elements of history are 

listed below.

CHIEF COMPLAINT (CC)

The CC is a concise statement describing the symptom, problem, condition, diagnosis, 

physician recommended return, or other factor that is the reason for the encounter.

DG: The medical record should clearly reflect the chief complaint.

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HISTORY OF PRESENT ILLNESS (HPI)

The HPI is a chronological description of the development of the patient's present illness 

from the first sign and/or symptom or from the previous encounter to the present. It 

includes the following elements:

location;

quality;

severity;

duration;

timing;

context;

modifying factors; and

associated signs and symptoms.

Brief and extended HPIs are distinguished by the amount of detail needed to 

accurately characterize the clinical problem(s).

A brief HPI consists of one to three elements of the HPI.

DG: The medical record should describe one to three elements of the present 

illness (HPI).

An extended HPI consists of four or more elements of the HPI.

DG: The medical record should describe four or more elements of the present 

illness (HPI) or associated comorbidities.

REVIEW OF SYSTEMS (ROS)

A ROS is an inventory of body systems obtained through a series of questions seeking 

to identify signs and/or symptoms which the patient may be experiencing or has 

experienced.

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For purposes of ROS, the following systems are recognized:

Constitutional symptoms (e.g., fever, weight loss)

Eyes

Ears, Nose, Mouth, Throat

Cardiovascular

Respiratory

Gastrointestinal

Genitourinary

Musculoskeletal

Integumentary (skin and/or breast)

Neurological

Psychiatric

Endocrine

Hematologic/Lymphatic

Allergic/Immunologic

A problem pertinent ROS inquires about the system directly related to the problem(s) 

identified in the HPI.

DG: The patient's positive responses and pertinent negatives for the system 

related to the problem should be documented.

An extended ROS inquires about the system directly related to the problem(s) identified 

in the HPI and a limited number of additional systems.

DG: The patient's positive responses and pertinent negatives for two to nine 

systems should be documented.

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A complete ROS inquires about the system(s) directly related to the problem(s) 

identified in the HPI plus all additional body systems.

DG: At least ten organ systems must be reviewed. Those systems with positive 

or pertinent negative responses must be individually documented. For the 

remaining systems, a notation indicating all other systems are negative is 

permissible. In the absence of such a notation, at least ten systems must be 

individually documented.

PAST, FAMILY, AND/OR SOCIAL HISTORY (PFSH)

The PFSH consists of a review of three areas:

past history (the patient's past experiences with illnesses, operations, injuries and 

treatments);

family history (a review of medical events in the patient's family, including 

diseases which may be hereditary or place the patient at risk); and

social history (an age appropriate review of past and current activities).

For the categories of subsequent hospital care, follow-up inpatient consultations and 

subsequent nursing facility care, CPT requires only an "interval" history. It is not 

necessary to record information about the PFSH.

A pertinent PFSH is a review of the history area(s) directly related to the problem(s) 

identified in the HPI.

DG: At least one specific item from any of the three history areas must be 

documented for a pertinent PFSH.

A complete PFSH is of a review of two or all three of the PFSH history areas, 

depending on the category of the E/M service. A review of all three history areas is 

required for services that by their nature include a comprehensive assessment or 

reassessment of the patient. A review of two of the three history areas is sufficient for 

other services.

DG: At least one specific item from two of the three history areas must be 

documented for a complete PFSH for the following categories of E/M services: 

office or other outpatient services, established patient; emergency department; 

subsequent nursing facility care; domiciliary care, established patient; and home 

care, established patient.

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DG: At least one specific item from each of the three history areas must be 

documented for a complete PFSH for the following categories of E/M services: 

office or other outpatient services, new patient; hospital observation services; 

hospital inpatient services, initial care; consultations; comprehensive nursing 

facility assessments; domiciliary care, new patient; and homecare, new patient.

B. DOCUMENTATION OF EXAMINATION

The levels of E/M services are based on four types of examination that are defined as 

follows:

Problem Focused -- a limited examination of the affected body area or organ 

system.

Expanded Problem Focused -- a limited examination of the affected body area 

or organ system and other symptomatic or related organ system(s).

Detailed -- an extended examination of the affected body area(s) and other 

symptomatic or related organ system(s).

Comprehensive -- a general multi-system examination or complete examination 

of a single organ system.

For purposes of examination, the following body areas are recognized:

Head, including the face

Neck

Chest, including breasts and axillae

Abdomen

Genitalia, groin, buttocks

Back, including spine

Each extremity

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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.

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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. 

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Generally, decision making with respect to a diagnosed problem is easier than that for 

an identified but undiagnosed problem. The number and type of diagnostic tests 

employed may be an indicator of the number of possible diagnoses. Problems which 

are improving or resolving are less complex than those which are worsening or failing to 

change as expected. The need to seek advice from others is another indicator of 

complexity of diagnostic or management problems.

DG: For each encounter, an assessment, clinical impression, or diagnosis should 

be documented. It may be explicitly stated or implied in documented decisions 

regarding management plans and/or further evaluation.

For a presenting problem with an established diagnosis the record should 

reflect whether the problem is: a) improved, well controlled, resolving or 

resolved; or, b) inadequately controlled, worsening, or failing to change as 

expected.

For a presenting problem without an established diagnosis, the assessment 

or clinical impression may be stated in the form of a differential diagnoses or 

as "possible,” "probable,” or "rule out” (R/O) diagnoses.

DG: The initiation of, or changes in, treatment should be documented. Treatment 

includes a wide range of management options including patient instructions, 

nursing instructions, therapies, and medications.

DG: If referrals are made, consultations requested or advice sought, the record 

should indicate to whom or where the referral or consultation is made or from 

whom the advice is requested.

AMOUNT AND/OR COMPLEXITY OF DATA TO BE REVIEWED

The amount and complexity of data to be reviewed is based on the types of diagnostic 

testing ordered or reviewed. A decision to obtain and review old medical records and/or 

obtain history from sources other than the patient increases the amount and complexity 

of data to be reviewed. 

Discussion of contradictory or unexpected test results with the physician who performed 

or interpreted the test is an indication of the complexity of data being reviewed. On

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occasion the physician who ordered a test may personally review the image, tracing or 

specimen to supplement information from the physician who 

prepared the test report or interpretation; this is another indication of the complexity of 

data being reviewed.

DG: If a diagnostic service (test or procedure) is ordered, planned, scheduled, or 

performed at the time of the E/M encounter, the type of service, eg, lab or x-ray, 

should be documented.

DG: The review of lab, radiology and/or other diagnostic tests should be 

documented. An entry in a progress note such as "WBC elevated" or "chest xray unremarkable" is acceptable. Alternatively, the review may be documented 

by initialing and dating the report containing the test results.

DG: A decision to obtain old records or decision to obtain additional history from 

the family, caretaker or other source to supplement that obtained from the patient 

should be documented.

DG: Relevant finding from the review of old records, and/or the receipt of 

additional history from the family, caretaker or other source should be 

documented. If there is no relevant information beyond that already obtained, 

that fact should be documented. A notation of "Old records reviewed” or 

"additional history obtained from family” without elaboration is insufficient.

DG: The results of discussion of laboratory, radiology or other diagnostic tests 

with the physician who performed or interpreted the study should be 

documented.

DG: The direct visualization and independent interpretation of an image, tracing, 

or specimen previously or subsequently interpreted by another physician should 

be documented.

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RISK OF SIGNIFICANT COMPLICATIONS, MORBIDITY, AND/OR MORTALITY

The risk of significant complications, morbidity, and/or mortality is based on the risks 

associated with the presenting problem(s), the diagnostic procedure(s), and the 

possible management options.

DG: Comorbidities/underlying diseases or other factors that increase the 

complexity of medical decision making by increasing the risk of complications, 

morbidity, and/or mortality should be documented.

DG: If a surgical or invasive diagnostic procedure is ordered, planned, or 

scheduled at the time of the E/M encounter, the type of procedure eg, 

laparoscopy, should be documented.

DG: If a surgical or invasive diagnostic procedure is performed at the time of the 

E/M encounter, the specific procedure should be documented.

DG: The referral for or decision to perform a surgical or invasive diagnostic 

procedure on an urgent basis should be documented or implied.

The following table may be used to help determine whether the risk of significant 

complications, morbidity, and/or mortality is minimal, low, moderate, or high. Because 

the determination of risk is complex and not readily quantifiable, the table includes 

common clinical examples rather than absolute measures of risk. The assessment of 

risk of the presenting problem(s) is based on the risk related to the disease process 

anticipated between the present encounter and the next one. The assessment of risk of 

selecting diagnostic procedures and management options is based on the risk during 

and immediately following any procedures or treatment. The highest level of risk in any 

one category (presenting problem(s), diagnostic procedure(s), or management options) 

determines the overall risk.

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Table of Risk

Level of Risk Presenting Problem(s) Diagnostic Procedure(s) Ordered Management Options Selected 

Minimal 

One self-limited or minor 

problem, eg, cold, insect bite, 

tinea corporis 

Laboratory tests requiring 

venipuncture 

Chest x-rays 

EKG/EEG 

Urinalysis

Ultrasound, eg, 

echocardiography 

KOH prep 

Rest

Gargles 

Elastic bandages

Superficial dressings 

Low 

Two or more self-limited or 

minor problems 

One stable chronic illness, eg, 

well controlled hypertension, 

non-insulin dependent 

diabetes, cataract, BPH

Acute uncomplicated illness or 

injury, eg, cystitis, allergic 

rhinitis, simple sprain 

Physiologic tests not under 

stress, eg, pulmonary function 

tests

Non-cardiovascular imaging 

studies with contrast, eg, barium 

enema

Superficial needle biopsies 

Clinical 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, eg, lump 

in breast 

Acute illness with systemic 

symptoms, eg, pyelonephritis, 

pneumonitis, colitis 

Acute complicated injury, eg, 

head injury with brief loss of 

consciousness 

Physiologic tests under stress, 

eg, 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, eg, arteriogram, 

cardiac catheterization 

Obtain fluid from body cavity, eg 

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 additives 

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 pose a threat to life 

or bodily function, eg, 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, eg, seizure, TIA, 

weakness, 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 

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D. DOCUMENTATION OF AN ENCOUNTER DOMINATED BY COUNSELING OR 

COORDINATION OF CARE

In the case where counseling and/or coordination of care dominates (more than 50%) of 

the physician/patient and/or family encounter (face-to-face time in the office or other 

outpatient setting or floor/unit time in the hospital or nursing facility), time is considered 

the key or controlling factor to qualify for a particular level of E/M services.

DG: If the physician elects to report the level of service based on counseling 

and/or coordination of care, the total length of time of the encounter (face-to-face 

or floor time, as appropriate) should be documented and the record should 

describe the counseling and/or activities to coordinate care.

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1997 DOCUMENTATION GUIDELINES FOR

EVALUATION & MANAGEMENT SERVICES

TABLE OF CONTENTS

Introduction ..........................................................................................................2

What Is Documentation and Why Is it Important?..................................2

What Do Payers Want and Why? .............................................................2

General Principles of Medical Record Documentation ..................................... 3

Documentation of E/M Services........................................................................... 4

Documentation of History .................................................................................... 5

Chief Complaint (CC) ................................................................................. 6

History of Present Illness (HPI) .................................................................7

Review of Systems (ROS) ......................................................................... 8

Past, Family and/or Social History (PFSH) .............................................. 9

Documentation of Examination ........................................................................... 10

General Multi-System Examinations ........................................................ 11

Single Organ System Examinations .........................................................12

Content and Documentation Requirements ............................................ 13

 General Multi-System Examination .................................................... 13

 Cardiovascular Examination .................................................................18

 Ear, Nose and Throat Examination .......................................................20

 Eye Examination .................................................................................... 23

 Genitourinary Examination ................................................................... 25

 Hematologic/Lymphatic/Immunologic Examination ...........................29

 Musculoskeletal Examination ............................................................... 31

 Neurological Examination ..................................................................... 34

 Psychiatric Examination ........................................................................37

 Respiratory Examination .......................................................................39

 Skin Examination ................................................................................... 41
15 Reference 38

Documentation of the Complexity of Medical Decision Making .......................43

Number of Diagnoses or Management Options ......................................44

Amount and/or Complexity of Data to Be Reviewed .............................. 45

Risk of Significant Complications, Morbidity, and/or Mortality ............ 46

Table of Risk ...............................................................................................47

Documentation of an Encounter Dominated by Counseling or Coordination 

of Care ..................................................................................................48
15 Reference 39

I. INTRODUCTION

WHAT IS DOCUMENTATION AND WHY IS IT IMPORTANT?

Medical record documentation is required to record pertinent facts, findings, and 

observations about an individual’s health history including past and present 

illnesses, examinations, tests, treatments, and outcomes. The medical record 

chronologically documents the care of the patient and is an important element 

contributing to high quality care. The medical record facilitates:

the ability of the physician and other healthcare professionals to evaluate 

and plan the patient’s immediate treatment, and to monitor his/her 

healthcare over time.

communication and continuity of care among physicians and other 

healthcare professionals involved in the patient’s care;

accurate and timely claims review and payment;

appropriate utilization review and quality of care evaluations; and

collection of data that may be useful for research and education.

An appropriately documented medical record can reduce many of the hassles 

associated with claims processing and may serve as a legal document to verify 

the care provided, if necessary.

WHAT DO PAYERS WANT AND WHY?

Because payers have a contractual obligation to enrollees, they may require 

reasonable documentation that services are consistent with the insurance 

coverage provided. They may request information to validate:

the site of service;

the medical necessity and appropriateness of the diagnostic and/or 

therapeutic services provided; and/or

that services provided have been accurately reported.

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II. GENERAL PRINCIPLES OF MEDICAL RECORD DOCUMENTATION

The principles of documentation listed below are applicable to all types of 

medical and surgical services in all settings. For Evaluation and Management 

(E/M) services, the nature and amount of physician work and documentation 

varies by type of service, place of service and the patient’s status. The general 

principles listed below may be modified to account for these variable 

circumstances in providing E/M services.

1. The medical record should be complete and legible.

2. The documentation of each patient encounter should include:

reason for encounter and relevant history, physical examination 

findings, and prior diagnostic test results;

assessment, clinical impression, or diagnosis;

plan for care; and

date and legible identity of the observer.

3. If not documented, the rationale for ordering diagnostic and other ancillary 

services should be easily inferred.

4. Past and present diagnoses should be accessible to the treating and/or 

consulting physician.

5. Appropriate health risk factors should be identified.

6. The patient’s progress, response to and changes in treatment, and revision 

of diagnosis should be documented.

7. The CPT and ICD-9-CM codes reported on the health insurance claim 

form should be supported by the documentation in the medical 

record.

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III. DOCUMENTATION OF E/M SERVICES

This publication provides definitions and documentation guidelines for the three 

key components of E/M services and for visits which consist predominately of 

counseling or coordination of care. The three key components--history, 

examination, and medical decision making--appear in the descriptors for office 

and other outpatient services, hospital observation services, hospital inpatient 

services, consultations, emergency department services, nursing facility 

services, domiciliary care services, and home services. While some of the text of 

CPT has been repeated in this publication, the reader should refer to CPT for the 

complete descriptors for E/M services and instructions for selecting a level of 

service. Documentation guidelines are identified by the symbol • DG. 

The descriptors for the levels of E/M services recognize seven components which 

are used in defining the levels of E/M services. These components are: 

history; 

examination; 

medical decision making; 

counseling; 

coordination of care; 

nature of presenting problem; and 

time. 

The first three of these components (i.e., history, examination and medical 

decision making) are the key components in selecting the level of E/M services. In 

the case of visits which consist predominantly of counseling or coordination of 

care, time is the key or controlling factor to qualify for a particular level of E/M 

service. 

Because the level of E/M service is dependent on two or three key components, 

performance and documentation of one component (eg, examination) at the 

highest level does not necessarily mean that the encounter in its entirety qualifies 

for the highest level of E/M service. 

These Documentation Guidelines for E/M services reflect the needs of the typical 

adult population. For certain groups of patients, the recorded information may 

vary slightly from that described here. Specifically, the medical records of infants, 

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children, adolescents and pregnant women may have additional or modified 

information recorded in each history and examination area. 

As an example, newborn records may include under history of the present illness 

(HPI) the details of mother's pregnancy and the infant's status at birth; social 

history will focus on family structure; family history will focus on congenital 

anomalies and hereditary disorders in the family. In addition, the content of a 

pediatric examination will vary with the age and development of the child. 

Although not specifically defined in these documentation guidelines, these 

patient group variations on history and examination are appropriate.

A. DOCUMENTATION OF HISTORY

The levels of E/M services are based on four levels of history (Problem Focused, 

Expanded Problem Focused, Detailed, and Comprehensive). Each type of history 

includes some or all of the following elements:

Chief complaint (CC)

History of present illness (HPI)

Review of systems (ROS) and

Past, family, and/or social history (PFSH).

The extent of the history of present illness, review of systems, and past, family 

and/or social history that is obtained and documented is dependent upon clinical 

judgment and the nature of the presenting problem(s).

The chart below shows the progression of the elements required for each type of 

history. To qualify for a given type of history all three elements in the table must 

be met. (A chief complaint is indicated at all levels.)

History of Present 

Illness (HPI) 

Review of Systems 

(ROS) 

Past, Family, and/or 

Social History (PFSH) 

Type of History 

Brief N/A N/A Problem Focused 

Brief Problem Problem Pertinent N/A Focused Expanded 

Problem 

Extended Extended Pertinent Detailed 

Extended Complete Complete Comprehensive 

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DG: The CC, ROS and PFSH may be listed as separate elements of history, 

or they may be included in the description of the history of the present 

illness.

DG: A ROS and/or a PFSH obtained during an earlier encounter does not 

need to be re-recorded if there is evidence that the physician reviewed and 

updated the previous information. This may occur when a physician 

updates his/her own record or in an institutional setting or group practice 

where many physicians use a common record. The review and update may 

be documented by:

describing any new ROS and/or PFSH information or noting there has 

been no change in the information; and

noting the date and location of the earlier ROS and/or PFSH.

DG: The ROS and/or PFSH may be recorded by ancillary staff or on a form 

completed by the patient. To document that the physician reviewed the 

information, there must be a notation supplementing or confirming the 

information recorded by others.

DG: If the physician is unable to obtain a history from the patient or other 

source, the record should describe the patient’s condition or other 

circumstance that precludes obtaining a history.

Definitions and specific documentation guidelines for each of the elements of 

history are listed below.

CHIEF COMPLAINT (CC)

The CC is a concise statement describing the symptom, problem, condition, 

diagnosis, physician recommended return, or other factor that is the reason for 

the encounter, usually stated in the patient’s own words.

DG: The medical record should clearly reflect the chief complaint.

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HISTORY OF PRESENT ILLNESS (HPI)

The HPI is a chronological description of the development of the patient’s present 

illness from the first sign and/or symptom or from the previous encounter to the 

present. It includes the following elements: 

location ,

quality ,

severity, 

duration, 

timing,

context ,

modifying factors, and

associated signs and symptoms.

Brief and extended HPIs are distinguished by the amount of detail needed to 

accurately characterize the clinical problem(s). 

A brief HPI consists of one to three elements of the HPI.

DG: The medical record should describe one to three elements of the 

present illness (HPI).

An extended HPI consists of at least four elements of the HPI or the status of at 

least three chronic or inactive conditions.

DG: The medical record should describe at least four elements of the 

present illness (HPI), or the status of at least three chronic or inactive 

conditions.

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REVIEW OF SYSTEMS (ROS)

A ROS is an inventory of body systems obtained through a series of questions 

seeking to identify signs and/or symptoms that the patient may be experiencing 

or has experienced. 

For purposes of ROS, the following systems are recognized:

Constitutional Symptoms (eg, fever, weight loss)

Eyes

Ears, Nose, Mouth, and Throat

Cardiovascular

Respiratory

Gastrointestinal

Genitourinary

Musculoskeletal

Integumentary (skin and/or breast)

Neurological

Psychiatric

Endocrine

Hematologic/Lymphatic

Allergic/Immunologic

A problem pertinent ROS inquires about the system directly related to the 

problem(s) identified in the HPI.

DG: The patient’s positive responses and pertinent negatives for the 

system related to the problem should be documented.

An extended ROS inquires about the system directly related to the problem(s) 

identified in the HPI and a limited number of additional systems.

DG: The patient’s positive responses and pertinent negatives for two to 

nine systems should be documented.

A complete ROS inquires about the system(s) directly related to the problem(s) 

identified in the HPI, plus all additional body systems.

DG: At least ten organ systems must be reviewed. Those systems with 

positive or pertinent negative responses must be individually documented. 

For the remaining systems, a notation indicating all other systems are 

negative is permissible. In the absence of such a notation, at least ten 

systems must be individually documented.

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PAST, FAMILY, AND/OR SOCIAL HISTORY (PFSH)

The PFSH consists of a review of three areas:

past history (the patient’s past experiences with illnesses, operations, 

injuries and treatments);

family history (a review of medical events in the patient’s family, including 

diseases which maybe hereditary or place the patient at risk); and

social history (an age appropriate review of past and current activities).

For certain categories of E/M services that include only an interval history, it is 

not necessary to record information about the PFSH. Those categories are 

subsequent hospital care, follow-up inpatient consultations and subsequent 

nursing facility care.

A pertinent PFSH is a review of the history area(s) directly related to the 

problem(s) identified in the HPI.

DG: At least one specific item from any of the three history areas must be 

documented for a pertinent PFSH.

A complete PFSH is a review of two or all three of the PFSH history areas, 

depending on the category of the E/M service. A review of all three history areas 

is required for services that by their nature include a comprehensive assessment 

or reassessment of the patient. A review of two of the three history areas is 

sufficient for other services.

DG: At least one specific item from two of the three history areas must be 

documented for a complete PFSH for the following categories of E/M 

services: office or other outpatient services, established patient; 

emergency department; domiciliary care, established patient; and home 

care, established patient.

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DG: At least one specific item from each of the three history areas must be 

documented for a complete PFSH for the following categories of E/M 

services: office or other outpatient services, new patient; hospital 

observation services; hospital inpatient services, initial care; 

consultations; comprehensive nursing facility assessments; domiciliary 

care, new patient; home care, new patient.

B. DOCUMENTATION OF EXAMINATION

The levels of E/M services are based on four types of examination:

Problem Focused – a limited examination of the affected body area or 

organ system.

Expanded Problem Focused – a limited examination of the affected body 

area or organ system and any other symptomatic or related body area(s) or 

organ system(s).

Detailed – an extended examination of the affected body area(s) or organ 

system(s) and any other symptomatic or related body area(s) or organ 

system(s).

Comprehensive – a general multi-system examination, or complete 

examination of a single organ system and other symptomatic or related 

body area(s) or organ system(s).

These types of examinations have been defined for general multi-system and the 

following single organ systems:

Cardiovascular

Ears, Nose, Mouth, and Throat

Eyes

Genitourinary (Female)

Genitourinary (Male)

Hematologic/Lymphatic/Immunologic

Musculoskeletal

Neurological

Psychiatric

Respiratory

Skin

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A general multi-system examination or a single organ system examination may 

be performed by any physician, regardless of specialty. The type (general multisystem or single organ system) and content of examination are selected by the 

examining physician and are based upon clinical judgment, the patient’s history, 

and the nature of the presenting problem(s).

The content and documentation requirements for each type and level of 

examination are summarized below and described in detail in tables beginning on 

page 13. In the tables, organ systems and body areas recognized by CPT for 

purposes of describing examinations are shown in the left column. The content, 

or individual elements, of the examination pertaining to that body area or organ 

system are identified by bullets (•) in the right column.

Parenthetical examples “(eg,...)”, have been used for clarification and to provide 

guidance regarding documentation. Documentation for each element must 

satisfy any numeric requirements (such as “Measurement of any three of the 

following seven...”) included in the description of the element. Elements with 

multiple components but with no specific numeric requirement (such as 

“Examination of liver and spleen”) require documentation of at least one 

component. It is possible for a given examination to be expanded beyond what is 

defined here. When that occurs, findings related to the additional systems and/or 

areas should be documented.

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 any 

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).

GENERAL MULTI-SYSTEM EXAMINATIONS

General multi-system examinations are described in detail beginning on page 13. 

To qualify for a given level of multi-system examination, the following content 

and documentation requirements should be met:

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Problem Focused Examination – should include performance and 

documentation of one to five elements identified by a bullet (•) in one or 

more organ system(s) or body area(s).

Expanded Problem Focused Examination – should include performance 

and documentation of at least six elements identified by a bullet (•) in one 

or more organ system(s) or body area(s).

Detailed Examination – should include at least six organ systems or body 

areas. For each system/area selected, performance and documentation of 

at least two elements identified by a bullet (•) is expected. Alternatively, a 

detailed examination may include performance and documentation of at 

least twelve elements identified by a bullet (•) in two or more organ systems 

or body areas.

Comprehensive Examination – should include at least nine organ systems 

or body areas. For each system/area selected, all elements of the 

examination identified by a bullet (•) should be performed, unless specific 

directions limit the content of the examination. For each area/system, 

documentation of at least two elements identified by a bullet is expected.

SINGLE ORGAN SYSTEM EXAMINATIONS

The single organ system examinations recognized by CPT are described in detail 

beginning on page 18. Variations among these examinations in the organ 

systems and body areas identified in the left columns and in the elements of the 

examinations described in the right columns reflect differing emphases among 

specialties. To qualify for a given level of single organ system examination, the 

following content and documentation requirements should be met:

Problem Focused Examination – should include performance and 

documentation of one to five elements identified by a bullet (•), whether in a 

box with a shaded or unshaded border.

Expanded Problem Focused Examination – should include performance 

and documentation of at least six elements identified by a bullet (•), 

whether in a box with a shaded or unshaded border.

Detailed Examination – examinations other than the eye and psychiatric 

examinations should include performance and documentation of at least 

twelve elements identified by a bullet (•), whether in a box with a shaded or 

unshaded border.

Eye and psychiatric examinations should include the performance 

and documentation of at least nine elements identified by a bullet (•), 

whether in a box with a shaded or unshaded border.

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Comprehensive Examination – should include performance of all elements 

identified by a bullet (•), whether in a shaded or unshaded box. 

Documentation of every element in each box with a shaded border and at 

least one element in a box with an unshaded border is expected.

CONTENT AND DOCUMENTATION REQUIREMENTS 

General Multi-System Examination 

System/Body 

Area 

Elements of Examination 

Constitutional Measurement of any three of the following seven vital signs: 1) sitting or 

 standing blood pressure, 2) supine blood pressure, 3) pulse rate and 

 regularity, 4) respiration, 5) temperature, 6) height, 7) weight (May be 

 measured and recorded by ancillary staff) 

General appearance of patient (eg, development, nutrition, body habitus, 

 deformities, attention to grooming) 

Eyes Inspection of conjunctivae and lids 

Examination of pupils and irises (eg, reaction to light and accommodation, 

 size and symmetry)

 

Ophthalmoscopic examination of optic discs (eg, size, C/D ratio, appearance)

 and posterior segments (eg, vessel changes, exudates, hemorrhages)

Ears, Nose, 

Mouth and 

Throat 

External inspection of ears and nose (eg, overall appearance, scars, lesions, 

 masses) 

Otoscopic examination of external auditory canals and tympanic membranes

Assessment of hearing (eg, whispered voice, finger rub, tuning fork) 

Inspection of nasal mucosa, septum and turbinates 

Inspection of lips, teeth and gums 

Examination of oropharynx: oral mucosa, salivary glands, hard and soft 

 palates, tongue, tonsils and posterior pharynx 

Neck 

Examination of neck (eg, masses, overall appearance, symmetry, tracheal 

 position, crepitus) 

Examination of thyroid (eg, enlargement, tenderness, mass) 

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System/Body 

Area 

Elements of Examination 

Respiratory Assessment of respiratory effort (eg, intercostal retractions, use of accessory 

 muscles, diaphragmatic movement) 

Percussion of chest (eg, dullness, flatness, hyperresonance) 

Palpation of chest (eg, tactile fremitus) 

Auscultation of lungs (eg, breath sounds, adventitious sounds, rubs) 

Cardiovascular Palpation of heart (eg, location, size, thrills) 

Auscultation of heart with notation of abnormal sounds and murmurs 

Examination of: 

carotid arteries (eg, pulse amplitude, bruits) 

abdominal aorta (eg, size, bruits)

femoral arteries (eg, pulse amplitude, bruits) 

pedal pulses (eg, pulse amplitude)

extremities for edema and/or varicosities 

Chest (Breasts) Inspection of breasts (eg, symmetry, nipple discharge) 

Palpation of breasts and axillae (eg, masses or lumps, tenderness) 

Gastrointestinal 

(Abdomen) 

Examination of abdomen with notation of presence of masses or tenderness

Examination of liver and spleen 

Examination for presence or absence of hernia 

Examination (when indicated) of anus, perineum and rectum, including sphincter 

 tone, presence of hemorrhoids, rectal masses 

Obtain stool sample for occult blood test when indicated 

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System/Body Elements of Examination 

Area 

Genitourinary MALE: 

Examination of the scrotal contents (eg, hydrocele, spermatocele, tenderness of 

 cord, testicular mass) 

Examination of the penis 

Digital rectal examination of prostate gland (eg, size, symmetry, nodularity, 

 tenderness) 

FEMALE: 

Pelvic examination (with or without specimen collection for smears and cultures), 

including 

Examination of external genitalia (eg, general appearance, hair distribution, 

 lesions) and vagina (eg, general appearance, estrogen effect, discharge, lesions, 

 pelvic support, cystocele, rectocele) 

Examination of urethra (eg, masses, tenderness, scarring) 

Examination of bladder (eg, fullness, masses, tenderness) 

Cervix (eg, general appearance, lesions, discharge) 

Uterus (eg, size, contour, position, mobility, tenderness, consistency, descent or 

 support) 

Adnexa/parametria (eg, masses, tenderness, organomegaly, nodularity) 

Lymphatic Palpation of lymph nodes in two or more areas: 

Neck 

Axillae 

Groin 

Other 

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System/Body Elements of Examination 

Area 

Musculoskeletal Examination of gait and station 

Inspection and/or palpation of digits and nails (eg, clubbing, cyanosis, 

 inflammatory conditions, petechiae, ischemia, infections, nodes) 

Examination of joints, bones and muscles of one or more of the following six areas: 1) 

head and neck; 2) spine, ribs and pelvis; 3) right upper extremity; 4) left upper extremity; 

5) right lower extremity; and 6) left lower extremity. The examination of a given area 

includes: 

Inspection and/or palpation with notation of presence of any misalignment, 

 asymmetry, crepitation, defects, tenderness, masses, effusions 

Assessment of range of motion with notation of any pain, crepitation or 

 contracture 

Assessment of stability with notation of any dislocation (luxation), 

 subluxation or laxity 

Assessment of muscle strength and tone (eg, flaccid, cog wheel, spastic) 

 with notation of any atrophy or abnormal movements 

Skin Inspection of skin and subcutaneous tissue (eg, rashes, lesions, ulcers) 

Palpation of skin and subcutaneous tissue (eg, induration, subcutaneous 

 nodules, tightening)

Neurologic Test cranial nerves with notation of any deficits 

Examination of deep tendon reflexes with notation of pathological reflexes (eg, 

 Babinski) 

Examination of sensation (eg, by touch, pin, vibration, proprioception) 

Psychiatric Description of patient’s judgment and insight 

Brief assessment of mental status including:

orientation to time, place and person 

recent and remote memory 

mood and affect (eg, depression, anxiety, agitation) 

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Content and Documentation Requirements 

Level of Exam Perform and Document: 

Problem Focused One to five elements identified by a bullet. 

Expanded Problem 

Focused At least six elements identified by a bullet. 

Detailed At least two elements identified by a bullet from each of six 

areas/systems 

OR at least twelve elements identified by a bullet in two or more 

areas/systems. 

Comprehensive Perform all elements identified by a bullet in at least nine organ systems or 

body areas and document at least two elements identified by a bullet from 

each of nine areas/systems.

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Cardiovascular Examination 

System/Body 

Area 

Elements of Examination 

Constitutional Measurement of any three of the following seven vital signs: 1) sitting 

or standing blood pressure, 2) supine blood pressure, 3) pulse rate and 

 regularity, 4) respiration, 5) temperature, 6) height, 7) weight (May be 

 measured and recorded by ancillary staff) 

General appearance of patient (eg, development, nutrition, body habitus, 

 deformities, attention to grooming)

Head and Face 

Eyes Inspection of conjunctivae and lids (eg, xanthelasma) 

Ears, Nose, 

Mouth and 

Throat 

Inspection of teeth, gums and palate 

Inspection of oral mucosa with notation of presence of pallor or cyanosis 

Neck 

Examination of jugular veins (eg, distension; a, v or cannon a waves)

Examination of thyroid (eg, enlargement, tenderness, mass) 

Respiratory Assessment of respiratory effort (eg, intercostal retractions, use of accessory 

 muscles, diaphragmatic movement) 

Auscultation of lungs (eg, breath sounds, adventitious sounds, rubs)

Cardiovascular Palpation of heart (eg, location, size and forcefulness of the point of maximal 

 impact; thrills; lifts; palpable S3 or S4)

Auscultation of heart including sounds, abnormal sounds and murmurs 

Measurement of blood pressure in two or more extremities when indicated 

 (eg, aortic dissection, coarctation) 

Examination of: 

Carotid arteries (eg, waveform, pulse amplitude, bruits, apical-carotid delay)

Abdominal aorta (eg, size, bruits) 

Femoral arteries (eg, pulse amplitude, bruits) 

Pedal pulses (eg, pulse amplitude) 

Extremities for peripheral edema and/or varicosities

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System/Body 

Area 

Elements of Examination 

Chest

(Breasts)

Gastrointestinal

(Abdomen) 

Examination of abdomen with notation of presence of masses or tenderness

Examination of liver and spleen

Obtain stool sample for occult blood from patients who are being considered 

 for thrombolytic or anticoagulant therapy

Genitourinary 

(Abdomen) 

Lymphatic 

Musculoskeletal Examination of the back with notation of kyphosis or scoliosis 

Examination of gait with notation of ability to undergo exercise testing and/or 

 participation in exercise programs 

Assessment of muscle strength and tone (eg, flaccid, cog wheel, spastic) 

 with notation of any atrophy and abnormal movements

Extremities Inspection and palpation of digits and nails (eg, clubbing, cyanosis, 

 inflammation, petechiae, ischemia, infections, Osler’s nodes)

Skin Inspection and/or palpation of skin and subcutaneous tissue (eg, stasis 

 dermatitis, ulcers, scars, xanthomas)

Neurological/ 

Psychiatric

Brief assessment of mental status including 

Orientation to time, place and person,

Mood and affect (eg, depression, anxiety, agitation)

Content and Documentation Requirements 

Level of Exam Perform and Document: 

Problem Focused One to five elements identified by a bullet. 

Expanded Problem 

Focused 

At least six elements identified by a bullet. 

Detailed At least twelve elements identified by a bullet. 

Comprehensive Perform all elements identified by a bullet; document every element in each box 

with a shaded border and at least one element in each box with an unshaded 

border. 

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Ear, Nose and Throat Examination

System/Body 

Area 

Elements of Examination 

Constitutional Measurement of any three of the following seven vital signs: 1) sitting or 

 standing blood pressure, 2) supine blood pressure, 3) pulse rate and 

 regularity, 4) respiration, 5) temperature, 6) height, 7) weight (May be 

 measured and recorded by ancillary staff) 

General appearance of patient (eg, development, nutrition, body habitus, 

 deformities, attention to grooming) 

Assessment of ability to communicate (eg, use of sign language or other 

 communication aids) and quality of voice 

Head and Face Inspection of head and face (eg, overall appearance, scars, lesions and 

 masses) 

Palpation and/or percussion of face with notation of presence or absence 

 of sinus tenderness 

Examination of salivary glands 

Assessment of facial strength 

Eyes Test ocular motility including primary gaze alignment

Ears, Nose, 

Mouth and 

Throat 

 Otoscopic examination of external auditory canals and tympanic membranes 

 including pneumo-otoscopy with notation of mobility of membranes 

Assessment of hearing with tuning forks and clinical speech reception 

 thresholds (eg, whispered voice, finger rub) 

External inspection of ears and nose (eg, overall appearance, scars, lesions 

 and masses) 

Inspection of nasal mucosa, septum and turbinates 

Inspection of lips, teeth and gums 

Examination of oropharynx: oral mucosa, hard and soft palates, tongue, 

 tonsils and posterior pharynx (eg, asymmetry, lesions, hydration of mucosal 

 surfaces) 

Inspection of pharyngeal walls and pyriform sinuses (eg, pooling of saliva, 

 asymmetry, lesions) 

Examination by mirror of larynx including the condition of the epiglottis, 

 false vocal cords, true vocal cords and mobility of larynx (Use of mirror not 

 required in children) 

Examination by mirror of nasopharynx including appearance of the mucosa, 

 adenoids, posterior choanae and eustachian tubes (Use of mirror not required 

 in children) 

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System/Body Elements of Examination 

Area 

Neck Examination of neck (eg, masses, overall appearance, symmetry, tracheal 

 position, crepitus)

Examination of thyroid (eg, enlargement, tenderness, mass)

Respiratory Inspection of chest including symmetry, expansion and/or assessment of 

 respiratory effort (eg, intercostal retractions, use of accessory muscles, 

 diaphragmatic movement)

Auscultation of lungs (eg, breath sounds, adventitious sounds, rubs) 

Cardiovascular Auscultation of heart with notation of abnormal sounds and murmurs 

Examination of peripheral vascular system by observation (eg, swelling, 

 varicosities) and palpation (eg, pulses, temperature, edema, tenderness)

Chest (Breasts) 

Gastrointestinal 

(Abdomen) 

Genitourinary 

Lymphatic Palpation of lymph nodes in neck, axillae, groin and/or other location 

Musculoskeletal 

Extremities 

Skin 

Neurological/ Test cranial nerves with notation of any deficits 

Psychiatric 

Brief assessment of mental status including 

Orientation to time, place and person, 

Mood and affect (eg, depression, anxiety, agitation) 

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Content and Documentation Requirements 

Level of Exam Perform and Document: 

Problem Focused One to five elements identified by a bullet. 

Expanded Problem 

Focused 

At least six elements identified by a bullet. 

Detailed At least twelve elements identified by a bullet. 

Comprehensive Perform all elements identified by a bullet; document every element in each 

box with a shaded border and at least one element in each box with an 

unshaded border.

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Eye Examination

System/Body Elements of Examination 

Area 

Constitutional 

Head and Face 

Eyes Test visual acuity (Does not include determination of refractive error)

Gross visual field testing by confrontation

Test ocular motility including primary gaze alignment

Inspection of bulbar and palpebral conjunctivae

Examination of ocular adnexae including lids (eg, ptosis or lagophthalmos), 

 lacrimal glands, lacrimal drainage, orbits and preauricular lymph nodes

Examination of pupils and irises including shape, direct and consensual

 reaction (afferent pupil), size (eg, anisocoria) and morphology

Slit lamp examination of the corneas including epithelium, stroma, 

 endothelium, and tear film

Slit lamp examination of the anterior chambers including depth, cells, and 

 flare

Slit lamp examination of the lenses including clarity, anterior and posterior 

 capsule, cortex, and nucleus

Measurement of intraocular pressures (except in children and patients with 

 trauma or infectious disease)

Ophthalmoscopic examination through dilated pupils (unless contraindicated) of

Optic discs including size, C/D ratio, appearance (eg, atrophy, cupping, 

 tumor elevation) and nerve fiber layer

Posterior segments including retina and vessels (eg, exudates and 

 hemorrhages)

Ears, Nose, 

Mouth and 

Throat 

Neck 

Respiratory 

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System/Body Elements of Examination 

Area 

Cardiovascular 

Chest (Breasts) 

Gastrointestinal 

(Abdomen) 

Genitourinary 

Lymphatic 

Musculoskeletal 

Extremities 

Skin 

Neurological/ Brief assessment of mental status including 

Psychiatric 

Orientation to time, place and person 

Mood and affect (eg, depression, anxiety, agitation) 

Content and Documentation Requirements 

Level of Exam Perform and Document: 

Problem Focused One to five elements identified by a bullet. 

Expanded Problem 

Focused At least six elements identified by a bullet. 

Detailed At least nine elements identified by a bullet. 

Comprehensive Perform all elements identified by a bullet; document every element in each 

box with a shaded border and at least one element in each box with an 

unshaded border.

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Genitourinary Examination

System/Body Elements of Examination 

Area 

Constitutional Measurement of any three of the following seven vital signs: 1) sitting or 

 standing blood pressure, 2) supine blood pressure, 3) pulse rate and 

 regularity, 4) respiration, 5) temperature, 6) height, 7) weight (May be 

 measured and recorded by ancillary staff) 

General appearance of patient (eg, development, nutrition, body habitus, 

 deformities, attention to grooming) 

Head and Face 

Eyes 

Ears, Nose, 

Mouth and 

Throat 

Neck 

Examination of neck (eg, masses, overall appearance, symmetry, tracheal 

 position, crepitus)

Examination of thyroid (eg, enlargement, tenderness, mass) 

Respiratory Assessment of respiratory effort (eg, intercostal retractions, use of accessory

 muscles, diaphragmatic movement)

Auscultation of lungs (eg, breath sounds, adventitious sounds, rubs)

Cardiovascular Auscultation of heart with notation of abnormal sounds and murmurs 

Examination of peripheral vascular system by observation (eg, swelling, 

 varicosities) and palpation (e.g. pulses, temperature, edema, tenderness)

Chest (Breasts) [See genitourinary (female)]

Gastrointestinal

(Abdomen) 

Examination of abdomen with notation of presence of masses or tenderness

Examination for presence or absence of hernia

Examination of liver and spleen

Obtain stool sample for occult blood when indicated

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System/Body Elements of Examination 

Area 

Genitourinary MALE:

Inspection of anus and perineum 

Examination (with or without specimen collection for smears and 

cultures) of genitalia including: 

Scrotum (eg, lesions, cysts, rashes) 

 

Epididymides (eg, size, symmetry, masses)

 

Testes (eg, size, symmetry, masses)

Urethral meatus (eg, size, location, lesions, discharge) 

Penis (eg, lesions, presence or absence of foreskin, foreskin 

 retractability, plaque, masses, scarring, deformities) 

Digital rectal examination including:

 

Prostate gland (eg, size, symmetry, nodularity, tenderness)

Seminal vesicles (eg, symmetry, tenderness, masses, enlargement)

Sphincter tone, presence of hemorrhoids, rectal masses 

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System/Body Elements of Examination 

Area 

Genitourinary

(Cont’d)

FEMALE: 

Includes at least seven of the following eleven elements identified by bullets: 

Inspection and palpation of breasts (eg, masses or lumps, tenderness, 

 symmetry, nipple discharge)

 Digital rectal examination including sphincter tone, presence of hemorrhoids, 

 rectal masses 

Pelvic examination (with or without specimen collection for smears and cultures) 

including:

External genitalia (eg, general appearance, hair distribution, lesions)

Urethral meatus (eg, size, location, lesions, prolapse)

Urethra (eg, masses, tenderness, scarring)

Bladder (eg, fullness, masses, tenderness)

Vagina (eg, general appearance, estrogen effect, discharge, lesions, pelvic 

 support, cystocele, rectocele)

Cervix (eg, general appearance, lesions, discharge)

Uterus (eg, size, contour, position, mobility, tenderness, consistency, descent 

 or support)

Adnexa/parametria (eg, masses, tenderness, organomegaly, nodularity)

Anus and perineum

Lymphatic Palpation of lymph nodes in neck, axillae, groin and/or other location 

Musculoskeletal 

Extremities 

Skin Inspection and/or palpation of skin and subcutaneous tissue (eg, rashes, lesions, 

 ulcers) 

Neurological/ Brief assessment of mental status including 

Psychiatric 

Orientation (eg, time, place and person) and 

Mood and affect (eg, depression, anxiety, agitation) 

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Content and Documentation Requirements 

Level of Exam Perform and Document: 

Problem Focused One to five elements identified by a bullet. 

Expanded Problem 

Focused 

At least six elements identified by a bullet. 

Detailed At least twelve elements identified by a bullet. 

Comprehensive Perform all elements identified by a bullet; document every element in each 

box with a shaded border and at least one element in each box with an 

unshaded border.

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Hematologic/Lymphatic/Immunologic Examination

System/Body Elements of Examination 

Area 

Constitutional Measurement of any three of the following seven vital signs: 1) sitting or

 standing blood pressure, 2) supine blood pressure, 3) pulse rate and 

 regularity, 4) respiration, 5) temperature, 6) height, 7) weight (May be 

 measured and recorded by ancillary staff) 

General appearance of patient (eg, development, nutrition, body habitus, 

 deformities, attention to grooming)

Head and Face Palpation and/or percussion of face with notation of presence or absence of sinus 

 tenderness 

Eyes Inspection of conjunctivae and lids 

Ears, Nose, 

Mouth and 

Throat

Otoscopic examination of external auditory canals and tympanic membranes

Inspection of nasal mucosa, septum and turbinates

Inspection of teeth and gums

Examination of oropharynx (eg, oral mucosa, hard and soft palates, tongue, 

 tonsils and posterior pharynx)

 

Neck 

Examination of neck (eg, masses, overall appearance, symmetry, tracheal

 position, crepitus) 

Examination of thyroid (eg, enlargement, tenderness, mass)

Respiratory Assessment of respiratory effort (eg, intercostal retractions, use of accessory 

 muscles, diaphragmatic movement) 

Auscultation of lungs (eg, breath sounds, adventitious sounds, rubs)

Cardiovascular Auscultation of heart with notation of abnormal sounds and murmurs 

Examination of peripheral vascular system by observation (eg, swelling, 

 varicosities) and palpation (pulses, temperature, edema, tenderness)

Chest (Breasts) 

Gastrointestinal

(Abdomen) 

Examination of abdomen with notation of presence of masses or tenderness

Examination of liver and spleen

Genitourinary 

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System/Body Elements of Examination 

Area 

Lymphatic Palpation of lymph nodes in neck, axillae, groin, and/or other location 

Musculoskeletal 

Extremities 

Inspection and palpation of digits and nails (eg, clubbing, cyanosis, 

 inflammation, petechiae, ischemia, infections, nodes)

Skin 

Inspection and/or palpation of skin and subcutaneous tissue (eg, rashes, 

 lesions, ulcers, ecchymoses, bruises)

Neurological/ Brief assessment of mental status including 

Psychiatric 

Orientation to time, place and person 

Mood and affect (eg, depression, anxiety, agitation) 

Content and Documentation Requirements 

Level of Exam Perform and Document: 

Problem Focused One to five elements identified by a bullet. 

Expanded Problem 

Focused At least six elements identified by a bullet. 

Detailed At least twelve elements identified by a bullet. 

Comprehensive Perform all elements identified by a bullet; document every element in each 

box with a shaded border and at least one element in each box with an 

unshaded border.

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Musculoskeletal Examination

System/Body Elements of Examination 

Area 

Constitutional Measurement of any three of the following seven vital signs: 1) sitting 

or standing blood pressure, 2) supine blood pressure, 3) pulse rate and 

 regularity, 4) respiration, 5) temperature, 6) height, 7) weight (May be 

 measured and recorded by ancillary staff) 

General appearance of patient (eg, development, nutrition, body habitus, 

 deformities, attention to grooming)

Head and Face

Eyes

Ears, Nose, 

Mouth and 

Throat

Neck

Respiratory 

Cardiovascular Examination of peripheral vascular system by observation (eg, swelling, 

 varicosities) and palpation (eg, pulses, temperature, edema, tenderness)

Chest (Breasts)

Gastrointestinal 

(Abdomen)

Genitourinary

Lymphatic Palpation of lymph nodes in neck, axillae, groin and/or other location 

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System/Body Elements of Examination 

Area 

Musculoskeletal Examination of gait and station 

Examination of joint(s), bone(s) and muscle(s)/ tendon(s) of four of the following six 

areas: 1) head and neck; 2) spine, ribs and pelvis; 3) right upper extremity; 4) left upper 

extremity; 5) right lower extremity; and 6) left lower extremity. The examination of a given 

area includes:

Inspection, percussion and/or palpation with notation of any misalignment,

 asymmetry, crepitation, defects, tenderness, masses or effusions

Assessment of range of motion with notation of any pain (eg, straight leg 

 raising), crepitation or contracture

Assessment of stability with notation of any dislocation (luxation), subluxation 

 or laxity

Assessment of muscle strength and tone (eg, flaccid, cog wheel, spastic) with 

 notation of any atrophy or abnormal movements

NOTE: For the comprehensive level of examination, all four of the elements identified by 

a bullet must be performed and documented for each of four anatomic areas. For the 

three lower levels of examination, each element is counted separately for each body 

area. For example, assessing range of motion in two extremities constitutes two 

elements.

Extremities [See musculoskeletal and skin]

Skin Inspection and/or palpation of skin and subcutaneous tissue (eg, scars, 

 rashes, lesions, cafe-au-lait spots, ulcers) in four of the following six areas: 

 1) head and neck; 2) trunk; 3) right upper extremity; 4) left upper extremity; 5) 

 right lower extremity; and 6) left lower extremity.

NOTE: For the comprehensive level, the examination of all four anatomic areas must be 

performed and documented. For the three lower levels of examination, each body area is 

counted separately. For example, inspection and/or palpation of the skin and 

subcutaneous tissue of two extremities constitutes two elements.

Neurological/

Psychiatric 

Test coordination (eg, finger/nose, heel/ knee/shin, rapid alternating 

 movements in the upper and lower extremities, evaluation of fine motor 

 coordination in young children)

Examination of deep tendon reflexes and/or nerve stretch test with notation of 

 pathological reflexes (eg, Babinski)

Examination of sensation (eg, by touch, pin, vibration, proprioception)

Brief assessment of mental status including

Orientation to time, place and person

Mood and affect (eg, depression, anxiety, agitation)

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Content and Documentation Requirements 

Level of Exam Perform and Document: 

Problem Focused One to five elements identified by a bullet. 

Expanded Problem 

Focused At least six elements identified by a bullet. 

Detailed At least twelve elements identified by a bullet. 

Comprehensive Perform all elements identified by a bullet; document every element in each 

box with a shaded border and at least one element in each box with an

unshaded border.

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Neurological Examination

System/Body Elements of Examination 

Area 

Constitutional Measurement of any three of the following seven vital signs: 1) sitting 

 or standing blood pressure, 2) supine blood pressure, 3) pulse rate and 

 regularity, 4) respiration, 5) temperature, 6) height, 7) weight (May be 

 measured and recorded by ancillary staff) 

General appearance of patient (eg, development, nutrition, body habitus, 

 deformities, attention to grooming)

Head and Face 

Eyes Ophthalmoscopic examination of optic discs (eg, size, C/D ratio, 

 appearance) and posterior segments (eg, vessel changes, exudates, 

 hemorrhages)

Ears, Nose, 

Mouth 

and Throat 

Neck 

Respiratory 

Cardiovascular Examination of carotid arteries (eg, pulse amplitude, bruits) 

Auscultation of heart with notation of abnormal sounds and murmurs 

Examination of peripheral vascular system by observation (eg, swelling,

 varicosities) and palpation (eg, pulses, temperature, edema, tenderness) 

Chest (Breasts) 

Gastrointestinal 

(Abdomen) 

Genitourinary 

Lymphatic 

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System/Body Elements of Examination 

Area 

Musculoskeletal Examination of gait and station

Assessment of motor function including:

Muscle strength in upper and lower extremities

Muscle tone in upper and lower extremities (eg, flaccid, cog wheel, 

 spastic) with notation of any atrophy or abnormal movements (eg, 

 fasciculation, tardive dyskinesia)

Extremities [See musculoskeletal] 

Skin 

Neurological Evaluation of higher integrative functions including:

Orientation to time, place and person

Recent and remote memory

Attention span and concentration

Language (eg, naming objects, repeating phrases, spontaneous speech)

Fund of knowledge (eg, awareness of current events, past history, 

 vocabulary)

Test the following cranial nerves:

2nd cranial nerve (eg, visual acuity, visual fields, fundi) 

3rd, 4th and 6th cranial nerves (eg, pupils, eye movements) 

5th cranial nerve (eg, facial sensation, corneal reflexes) 

7th cranial nerve (eg, facial symmetry, strength) 

8th cranial nerve (eg, hearing with tuning fork, whispered voice and/or 

 finger rub)

9th cranial nerve (eg, spontaneous or reflex palate movement) 

11th cranial nerve (eg, shoulder shrug strength) 

12th cranial nerve (eg, tongue protrusion)

Examination of sensation (eg, by touch, pin, vibration, proprioception)

Examination of deep tendon reflexes in upper and lower extremities with 

 notation of pathological reflexes (eg, Babinski)

Test coordination (eg, finger/nose, heel/knee/shin, rapid alternating 

 movements in the upper and lower extremities, evaluation of fine motor 

 coordination in young children)

Psychiatric 

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Content and Documentation Requirements 

Level of Exam Perform and Document: 

Problem Focused One to five elements identified by a bullet. 

Expanded Problem 

Focused 

At least six elements identified by a bullet. 

Detailed At least twelve elements identified by a bullet. 

Comprehensive Perform all elements identified by a bullet; document every element in each 

box with a shaded border and at least one element in each box with an 

unshaded border.

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Psychiatric Examination

System/Body Elements of Examination 

Area 

Constitutional Measurement of any three of the following seven vital signs: 1) 

 sitting or standing blood pressure, 2) supine blood pressure, 3) pulse 

 rate and regularity, 4) respiration, 5) temperature, 6) height, 7) weight 

 (May be measured and recorded by ancillary staff)

General appearance of patient (eg, development, nutrition, body 

 habitus, deformities, attention to grooming)

Head and Face 

Eyes 

Ears, Nose, 

Mouth and 

Throat 

Neck 

Respiratory 

Cardiovascular 

Chest (Breasts)

Gastrointestinal

(Abdomen) 

Genitourinary 

Lymphatic 

Musculoskeletal 

Assessment of muscle strength and tone (eg, flaccid, cog wheel,

 spastic) with notation of any atrophy and abnormal movements

Examination of gait and station 

Extremities 

Skin 

Neurological 

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System/Body 

Area 

Elements of Examination

Psychiatric Description of speech including: rate; volume; articulation; coherence; 

and spontaneity with notation of abnormalities (eg, perseveration, 

paucity of language) 

Description of thought processes including: rate of thoughts; content of 

thoughts (eg, logical vs. illogical, tangential); abstract reasoning; and 

computation 

Description of associations (eg, loose, tangential, circumstantial, intact) 

Description of abnormal or psychotic thoughts including: hallucinations; 

delusions; preoccupation with violence; homicidal or suicidal ideation; 

and obsessions 

Description of the patient’s judgment (eg, concerning everyday 

activities and social situations) and insight (eg, concerning psychiatric 

condition) 

Complete mental status examination including 

Orientation to time, place and person 

Recent and remote memory 

Attention span and concentration 

Language (eg, naming objects, repeating phrases) 

Fund of knowledge (eg, awareness of current events, past history, 

vocabulary) 

Mood and affect (eg, depression, anxiety, agitation, hypomania, lability) 

Content and Documentation Requirements 

Level of Exam Perform and Document: 

Problem Focused One to five elements identified by a bullet. 

Expanded Problem 

Focused 

At least six elements identified by a bullet. 

Detailed At least nine elements identified by a bullet. 

Comprehensive Perform all elements identified by a bullet; document every element in each 

box with a shaded border and at least one element in each box with an 

unshaded border.

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Respiratory Examination

System/Body 

Area 

Elements of Examination 

Constitutional Measurement of any three of the following seven vital signs: 1) sitting 

or standing blood pressure, 2) supine blood pressure, 3) pulse rate and 

 regularity, 4) respiration, 5) temperature, 6) height, 7) weight (May be 

 measured and recorded by ancillary staff) 

General appearance of patient (eg, development, nutrition, body habitus, 

 deformities, attention to grooming)

Head and Face 

Eyes 

Ears, Nose,

Mouth and 

Throat

Inspection of nasal mucosa, septum and turbinates

Inspection of teeth and gums

Examination of oropharynx (eg, oral mucosa, hard and soft palate, tongue, 

 tonsils and posterior pharynx)

Neck Examination of neck (eg, masses, overall appearance, symmetry, tracheal 

 position, crepitus)

Examination of thyroid (eg, enlargement, tenderness, mass) 

Examination of jugular veins (eg, distention, a, v or cannon a waves)

Respiratory Inspection of chest with notation of symmetry and expansion

Assessment of respiratory effort (eg, intercostal retractions, use of accessory 

 muscles, diaphragmatic movement)

Percussion of chest (eg, dullness, flatness, hyperresonance)

Palpation of chest (eg, tactile fremitus)

Auscultation of lungs (eg, breath sounds, adventitious sounds, rubs)

Cardiovascular Auscultation of heart with notation of abnormal sounds and murmurs 

Examination of peripheral vascular system by observation (eg, swelling, 

 varicosities) and palpation (pulses, temperature, edema, tenderness)

Chest 

(Breasts) 

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System/Body Elements of Examination 

Area 

Gastrointestinal

(Abdomen) 

Examination of abdomen with notation of presence of masses or tenderness

Examination of liver and spleen

Genitourinary 

Lymphatic Palpation of lymph nodes in neck, axillae, groin and/or other location 

Musculoskeletal 

Assessment of muscle strength and tone (eg, flaccid, cog wheel, spastic) 

 with notation of any atrophy and abnormal movements

Examination of gait and station 

Extremities 

Inspection and palpation of digits and nails (eg, clubbing, cyanosis, 

 inflammation, petechiae, ischemia, infections, nodes)

Skin Inspection and/or palpation of skin and subcutaneous tissue (eg, rashes, 

 lesions, ulcers) 

Neurological/ Brief assessment of mental status including 

Psychiatric 

Orientation to time, place and person 

Mood and affect (eg, depression, anxiety, agitation) 

Content and Documentation Requirements 

Level of Exam Perform and Document: 

Problem Focused One to five elements identified by a bullet. 

Expanded Problem 

Focused 

At least six elements identified by a bullet. 

Detailed At least twelve elements identified by a bullet.

Comprehensive Perform all elements identified by a bullet; document every element in each 

box with a shaded border and at least one element in each box with an 

unshaded border.

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Skin Examination

System/Body 

Area 

Elements of Examination 

Constitutional Measurement of any three of the following seven vital signs: 1) sitting 

 or standing blood pressure, 2) supine blood pressure, 3) pulse rate and 

 regularity, 4) respiration, 5) temperature, 6) height, 7) weight (May be 

 measured and recorded by ancillary staff) 

General appearance of patient (eg, development, nutrition, body

 habitus, deformities, attention to grooming)

Head and Face 

 

Eyes Inspection of conjunctivae and lids

Ears, Nose, 

Mouth and 

Throat

Inspection of teeth and gums 

Examination of oropharynx (eg, oral mucosa, hard and soft palates, 

 tongue, tonsils, posterior pharynx) 

Neck Examination of thyroid (eg, enlargement, tenderness, mass)

Respiratory 

Cardiovascular 

Examination of peripheral vascular system by observation (eg, 

 swelling, varicosities) and palpation (eg, pulses, temperature, edema, 

 tenderness)

Chest (Breasts)

Gastrointestinal 

(Abdomen)

Examination of liver and spleen

Examination of anus for condyloma and other lesions

Genitourinary 

Lymphatic Palpation of lymph nodes in neck, axillae, groin and/or other location

Musculoskeletal 

Extremities Inspection and palpation of digits and nails (eg, clubbing, cyanosis, 

 inflammation, petechiae, ischemia, infections, nodes)

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System/Body Elements of Examination 

Area 

Skin Palpation of scalp and inspection of hair of scalp, eyebrows, face,

 chest, pubic area (when indicated) and extremities 

Inspection and/or palpation of skin and subcutaneous tissue (eg, 

 rashes, lesions, ulcers, susceptibility to and presence of photo 

 damage) in eight of the following ten areas:

Head, including the face and 

Neck

Chest, including breasts and axillae 

Abdomen

Genitalia, groin, buttocks

Back

Right upper extremity

Left upper extremity

Right lower extremity

Left upper extremity

NOTE: For the comprehensive level, the examination of at least eight anatomic 

areas must be performed and documented. For the three lower levels of 

examination, each body area is counted separately. For example, inspection 

and/or palpation of the skin and subcutaneous tissue of the right upper extremity 

and the left upper extremity constitutes two elements.

Inspection of eccrine and apocrine glands of skin and subcutaneous 

 tissue with identification and location of any hyperhidrosis, 

 chromhidroses or bromhidrosis

Neurological/ Brief assessment of mental status including 

Psychiatric 

Orientation to time, place and person 

Mood and affect (eg, depression, anxiety, agitation) 

Content and Documentation Requirements 

Level of Exam Perform and Document: 

Problem Focused One to five elements identified by a bullet. 

Expanded Problem 

Focused At least six elements identified by a bullet. 

Detailed At least twelve elements identified by a bullet. 

Comprehensive Perform all elements identified by a bullet; document every element in each 

box with a shaded border and at least one element in each box with an 

unshaded border. 

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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 below. 

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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. 

Generally, decision making with respect to a diagnosed problem is easier than that for 

an identified but undiagnosed problem. The number and type of diagnostic tests 

employed may be an indicator of the number of possible diagnoses. Problems which 

are improving or resolving are less complex than those which are worsening or failing 

to change as expected. The need to seek advice from others is another indicator of 

complexity of diagnostic or management problems. 

DG: For each encounter, an assessment, clinical impression, or diagnosis 

should be documented. It may be explicitly stated or implied in 

documented decisions regarding management plans and/or further 

evaluation.

• For a presenting problem with an established diagnosis the record should 

reflect whether the problem is: a) improved, well controlled, resolving or 

resolved; or, b) inadequately controlled, worsening, or failing to change as 

expected. 

• For a presenting problem without an established diagnosis, the 

assessment or clinical impression may be stated in the form of differential 

diagnoses or as a "possible", "probable", or "rule out" (R/O) diagnosis. 

DG: The initiation of, or changes in, treatment should be documented. 

Treatment includes a wide range of management options including patient 

instructions, nursing instructions, therapies, and medications. 

DG: If referrals are made, consultations requested or advice sought, the record 

should indicate to whom or where the referral or consultation is made or 

from whom the advice is requested. 

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AMOUNT AND/OR COMPLEXITY OF DATA TO BE REVIEWED 

The amount and complexity of data to be reviewed is based on the types of diagnostic 

testing ordered or reviewed. A decision to obtain and review old medical records and/or 

obtain history from sources other than the patient increases the amount and complexity 

of data to be reviewed. 

Discussion of contradictory or unexpected test results with the physician who 

performed or interpreted the test is an indication of the complexity of data being 

reviewed. On occasion the physician who ordered a test may personally review the 

image, tracing or specimen to supplement information from the physician who 

prepared the test report or interpretation; this is another indication of the complexity of 

data being reviewed. 

DG: If a diagnostic service (test or procedure) is ordered, planned, scheduled, or 

performed at the time of the E/M encounter, the type of service, eg, lab or x-ray, 

should be documented. 

DG: The review of lab, radiology and/or other diagnostic tests should be documented. 

A simple notation such as "WBC elevated" or "chest x-ray unremarkable" is 

acceptable. Alternatively, the review may be documented by initialing and dating 

the report containing the test results. 

DG: A decision to obtain old records or decision to obtain additional history from the 

family, caretaker or other source to supplement that obtained from the patient 

should be documented. 

DG: Relevant findings from the review of old records, and/or the receipt of additional 

history from the family, caretaker or other source to supplement that obtained 

from the patient should be documented. If there is no relevant information 

beyond that already obtained, that fact should be documented. A notation of “Old 

records reviewed” or “additional history obtained from family” without elaboration 

is insufficient. 

DG: The results of discussion of laboratory, radiology or other diagnostic tests with 

the physician who performed or interpreted the study should be documented. 

DG: The direct visualization and independent interpretation of an image, tracing 

or specimen previously or subsequently interpreted by another physician 

should be documented. 

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RISK OF SIGNIFICANT COMPLICATIONS, MORBIDITY, AND/OR 

MORTALITY 

The risk of significant complications, morbidity, and/or mortality is based on the risks 

associated with the presenting problem(s), the diagnostic procedure(s), and the 

possible management options. 

DG: Comorbidities/underlying diseases or other factors that increase the 

complexity of medical decision making by increasing the risk of 

complications, morbidity, and/or mortality should be documented. 

DG: If a surgical or invasive diagnostic procedure is ordered, planned or 

scheduled at the time of the E/M encounter, the type of procedure, eg, 

laparoscopy, should be documented. 

DG: If a surgical or invasive diagnostic procedure is performed at the time of 

the E/M encounter, the specific procedure should be documented. 

DG: The referral for or decision to perform a surgical or invasive diagnostic 

procedure on an urgent basis should be documented or implied. 

The following table may be used to help determine whether the risk of significant 

complications, morbidity, and/or mortality is minimal, low, moderate, or high. Because 

the determination of risk is complex and not readily quantifiable, the table includes 

common clinical examples rather than absolute measures of risk. The assessment of 

risk of the presenting problem(s) is based on the risk related to the disease process 

anticipated between the present encounter and the next one. The assessment of risk of 

selecting diagnostic procedures and management options is based on the risk during 

and immediately following any procedures or treatment. The highest level of risk in 

any one category (presenting problem(s), diagnostic procedure(s), or 

management options) determines the overall risk. 

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TABLE OF RISK

Level of Risk Presenting Problem(s) Diagnostic Procedure(s) Ordered Management Options Selected 

Minimal 

One self-limited or minor 

problem, eg, cold, insect bite, 

tinea corporis 

Laboratory tests requiring 

venipuncture 

Chest x-rays 

EKG/EEG 

Urinalysis

Ultrasound, eg, 

echocardiography 

KOH prep 

Rest

Gargles 

Elastic bandages

Superficial dressings 

Low 

Two or more self-limited or 

minor problems 

One stable chronic illness, eg, 

well controlled hypertension, 

non-insulin dependent 

diabetes, cataract, BPH

Acute uncomplicated illness or 

injury, eg, cystitis, allergic 

rhinitis, simple sprain 

Physiologic tests not under 

stress, eg, pulmonary function 

tests

Non-cardiovascular imaging 

studies with contrast, eg, barium 

enema

Superficial needle biopsies 

Clinical 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, eg, lump 

in breast 

Acute illness with systemic 

symptoms, eg, pyelonephritis, 

pneumonitis, colitis 

Acute complicated injury, eg, 

head injury with brief loss of 

consciousness 

Physiologic tests under stress, 

eg, 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, eg, arteriogram, 

cardiac catheterization 

Obtain fluid from body cavity, eg 

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 additives 

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 pose a threat to life 

or bodily function, eg, 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, eg, seizure, TIA, 

weakness, 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 

47
15 Reference 85

D. DOCUMENTATION OF AN ENCOUNTER DOMINATED BY 

COUNSELING OR COORDINATION OF CARE 

In the case where counseling and/or coordination of care dominates (more than 50%) of 

the physician/patient and/or family encounter (face-to-face time in the office or other or 

outpatient setting, floor/unit time in the hospital or nursing facility), time is considered 

the key or controlling factor to qualify for a particular level of E/M services. 

DG: If the physician elects to report the level of service based on counseling 

and/or coordination of care, the total length of time of the encounter (faceto-face or floor time, as appropriate) should be documented and the 

record should describe the counseling and/or activities to coordinate care.

48
16 Request for Course 1

MEDICARE RESIDENT, PRACTICING PHYSICIAN, AND

OTHER HEALTH CARE PROFESSIONAL TRAINING PROGRAM

REQUEST FOR CENTERS FOR MEDICARE &

MEDICAID SERVICES-LED IN-PERSON COURSE

The Centers for Medicare & Medicaid Services (CMS) has a strong commitment to 

communicate accurate, consistent, and timely information about the Medicare 

Program to the nation’s health care professionals. The goal of the Medicare 

Resident, Practicing Physician, and Other Health Care Professional Training 

Program is to inform residents, practicing physicians, and other health care 

professionals who are new to the Medicare Program about the benefits of 

participation in the Program and the resources available to them as a Medicare 

provider. 

The 3-Hour Medicare Program Training Module consists of seven chapters that are 

based on information found in the Medicare Physician Guide: A Resource for 

Residents, Practicing Physicians, and Other Health Care Professionals. The table 

on page 2 lists the learning objectives for each chapter. Please circle the number 

that you believe best represents the importance of each chapter as it relates to the 

needs of the learners. Count the number of 2s and 3s that you circled. Add up the 

time required to present the chapters that you circled. Enter this information on 

page 3. 

Please note that resource constraints may limit a Regional Office’s (RO) ability to 

conduct in-person courses.
16 Request for Course 2

1 = Less Important 2 = Somewhat Important 3 = Very Important

CHAPTER LEARNING OBJECTIVES TIME LEVEL OF 

IMPORTANCE

1

Introduction to 

the Medicare 

Program

- Identify Medicare’s four parts 

- Determine the individuals who are eligible for 

Medicare Part A and Part B, Medicare 

Advantage, and the prescription drug plan

- Identify the organizations that impact the

Medicare Program

30 minutes 1 2 3

2

Becoming a 

Medicare 

Provider or 

Supplier

- Identify Part A and Part B providers and 

suppliers

- Define the Medicare physician and practitioner

- Describe the Medicare Program enrollment 

process

- Identify how providers and suppliers can 

promote cultural competency

35 minutes 1 2 3

3

Medicare 

Reimbursement

- Describe how Medicare providers and 

suppliers are reimbursed for the items and 

services they furnish

- Identify when Medicare is the secondary payer

- Recognize incentive payments

- Describe the Medicare Physician Fee 

Schedule

- Identify notices you may use or receive from 

Medicare

- Describe the other health insurance plans 

beneficiaries may be enrolled in

20 minutes 1 2 3

4

Medicare 

Payment Policies

- Determine Medicare covered services

- Identify incident to services

- Determine the services that are not covered by 

Medicare 

15 minutes 1 2 3

5

Evaluation and 

Management 

Services

- Describe the two common sets of codes that 

are currently in use and the new classification 

system that will be used beginning on October 1, 

2013.

- Identify the seven general principles of 

documentation

- Identify the seven components that define the 

levels of evaluation and management services

45 minutes 1 2 3

6

Protecting the 

Medicare Trust 

Fund

- Identify the goal of the Medicare Integrity 

Program

- Describe the medical review process

- Determine the two types of coverage 

determinations

- Define Federal health care fraud

- Define program abuse

- Identify the potential legal actions that may be

imposed if a provider, supplier, or health care 

organization has committed health care fraud 

and program abuse

15 minutes 1 2 3

7

Inquiries, 

Overpayments, 

and Fee-forService Appeals

- Describe how providers and suppliers can find 

answers to inquiries

- Identify the reasons overpayments are often 

paid

- Identify the five levels of the fee-for-service 

appeals process

- Define a reopening

20 minutes 1 2 3
16 Request for Course 3

Count the number of 2s and 3s that you circled on page 2.

Number of 2s and 3s circled = _______________

Add up the time required to present the chapters that you circled.

Time required to present all chapters = _______________

Please ensure that the total time for the chapters you have selected does not 

exceed the time available for learners to attend the course.

To request a CMS-led in-person Medicare Resident, Practicing, and Other Health Care 

Professional Training Program course, please mail or fax this form directly to your CMS 

Regional Office, ATTENTION: Request For Medicare Resident, Practicing Physician, 

and Other Health Care Professional Training Program Course. CMS RO mailing 

addresses and fax numbers can be found at http://www.cms.hhs.gov/RegionalOffices on 

the CMS website.

The developers of this program have no conflicts of interest to disclose.