As predicted, HCFA rejected the guidelines proposed by the AMA, and instead unveiled its own version. The details There are many differences between these guidelines and previous versions. Under the history of present illness, there are more details about documenting symptoms and patients on multiple medications. A detailed history now requires a complete Past Family Social History for documentation purposes. An expanded problem-focused history now requires a pertinent Past Family Social History.
Physicians can now mix and match organ systems and body areas for the four levels of exam.
Comprehensive Multi-System Exam 9 or more of the 10 body areas or 12 organ system HCFA has stated that three constitutional findings are comparable to one body area or organ system. The levels are now low, moderate and high. Use of vignettes Another big difference is that these guidelines will rely on specialty-specific vignettes. In fact, many view these vignettes as the foundation upon which the success of the guidelines rests. HCFA will work the specialty societies and an outside contractor to create vignettes for the physical exam and medical-decision making portions of the guidelines.