Advize Health EM Calculator

Advize Health provides professional medical auditing and consulting services to large health care payer organizations, small and large group practices, hospitals and clinics. Education services include ICD-10 training, DRG validations, Revenue Cycles Operations consulting and provider and staff coding and documentation improvement. If you have any questions about Advize Health or the Evaluation and Management (EM) CPT Coding Calculator please contact us.

Patient History
Examination
Medical Decision Making
Time

General

Service Type *

History of Present Illness (HPI)

Chief Complaint *

Chronic Diseases/Status

Location

Quality

Severity

Duration

Timing

Context

Modifying Factors

Associated Signs & Symptoms

Review of Systems (ROS)

Consitutional Symptoms

Eyes

Ears, Nose, Throat, Mouth

Cardiovascular

Respiratory

Gastrointestinal

Genitourinary

Musculoskeletal

Integumentary

Neurological

Psychiatric

Endocrine

Hematologic/Lymphatic

Allergic/Immunologic

All Others Reviewed & Negative

Past, Family, and Social History (PFSH)

Past

Current Medications

Prior Illnesses/Injuries

Dietary Status

Operations & Hospitalizations

Allergies

Age Appropriate Immunizations

Family

Health Status or Cause of Death of Parents, Siblings, and Children

Diseases Related to Chief Complaint, HPI, or ROS

Hereditary or High Risk Diseases

Social History

Living Arrangements

Marital Status

Sexual History

Occupational History

Use of Drugs, Alchohol, or Tobacco

Extent of Education

Current Employment

Other

Patient History unobtainable

Focused

Expanded

Detailed

Comprehensive

Exam Type

Body Areas and Organ Systems Exam (95)

Body Areas

Head, including the face

Neck

Chest, including breasts and axillae

Abdomen

Genitalia, groin, buttocks

Back, including spine

Right upper extremity

Left upper extremity

Right lower extremity

Left lower extremity

Organ Systems

Constitutional

Eyes

Ears, nose, mouth, and throat

Cardiovascular

Respiratory

Gastrointestinal

Genitourinary

Musculoskeletal

Skin

Neurologic

Psychiatric

Hematologic/Lymphatic/Immunologic

Detailed exam

General Multi-Sytem Exam (97)

Constitutional

Measurement of any three vital signs

General appearance of patient

Eyes

Inspection of conjunctivae and lids

Examination of pupils and irises

Ophthalmoscopic examination of optic discs

Ears, Nose, Mouth, and Throat

External inspection of ears and nose

Otoscopic examination of external auditory canals and tympanic membranes

Assessment of hearing

Inspection of nasal mucosa, septum and turbinate's

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

Examination of Thyroid

Respiratory

Assessment of respiratory effort

Percussion of chest

Palpitation of chest

Auscultation of lungs

Cardiovascular

Palpitation of heart

Auscultation of heart with notation of abnormal sounds and murmurs

Examination of carotid arteries

Examination of abdominal aorta

Examination of femoral arteries

Examination of pedal pulses

Examination of extremities for edema and/or varicosities

Chest/Breasts

Inspection of breasts

Palpation of breasts and axillae

Gastrointestinal

Examination of abdomen

Examination of liver and spleen

Examination for presence or absence of hernia

Examine anus, perineum, and rectum

Obtain stool sample for occult blood test when indicated

Genitourinary (M)

Examine the scrotal contents

Examination of penis

Digital rectal examination of prostate gland

Genitourinary (F)

Examination of external genitalia and vagina

Examination of urethra

Examination of bladder

Cervix

Uterus

Adnexa/parametria

Lymphatic

Palpation of lymph nodes in Neck

Palpation of lymph nodes in Axillae

Palpation of lymph nodes in Groin

Palpation of lymph nodes in other areas

Musculoskeletal

Examination of gait and station

Inspection and/or palpation of digits and nails

Musculoskeletal - Head & Neck

Head & Neck - Inspection and/or palpation

Head & Neck - Assessment of range of motion

Head & Neck - Assessment of stability

Head & Neck - Assessment of muscle strength and tone

Musculoskeletal - Spine, Ribs, & Pelvis

Spine, Ribs, & Pelvis - Inspection and/or palpation

Spine, Ribs, & Pelvis - Assessment of range of motion

Spine, Ribs, & Pelvis - Assessment of stability

Spine, Ribs, & Pelvis - Assessment of muscle strength and tone

Musculoskeletal - Left Upper Extremity

Left Upper Extremity - Inspection and/or palpation

Left Upper Extremity - Assessment of range of motion

Left Upper Extremity - Assessment of stability

Left Upper Extremity - Assessment of muscle strength and tone

Musculoskeletal - Right Upper Extremity

Right Upper Extremity - Inspection and/or palpation

Right Upper Extremity - Assessment of range of motion

Right Upper Extremity - Assessment of stability

Right Upper Extremity - Assessment of muscle strength and tone

Musculoskeletal - Left Lower Extremity

Left Lower Extremity - Inspection and/or palpation

Left Lower Extremity - Assessment of range of motion

Left Lower Extremity - Assessment of stability

Left Lower Extremity - Assessment of muscle strength and tone

Musculoskeletal - Right Lower Extremity

Right Lower Extremity - Inspection and/or palpation

Right Lower Extremity - Assessment of range of motion

Right Lower Extremity - Assessment of stability

Right Lower Extremity - Assessment of muscle strength and tone

Skin

Inspection of skin and subcutaneous tissue

Palpation of skin and subcutaneous tissue

Neurological

Test cranial nerves

Examination of deep tendon reflexes

Examination of sensation

Psychiatric

Description of patients judgement and insight

Brief assessment of mental status including orientation to time, place, and person

Brief assessment of mental status including recent and remote memory

Brief assessment of mental status including mood and affect

Cardiovascular Exam (97)

Constitutional

Measurement of any three vital signs

General appearance of patient

Eyes

Inspection of conjunctivae and lids

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

Examination of thyroid

Respiratory

Assessment of respiratory effort

Auscultation of lungs

Cardiovascular

Palpation of heart

Auscultation of heart including sounds, abnormal sounds and murmurs

Measurement of blood pressure in two or more extremities when indicated

Examination of Carotid arteries

Examination of Abdominal aorta

Examination of Femoral arteries

Examination of Pedal pulses

Examination of Extremities for peripheral edema and/or varicosities

Gastrointestinal

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

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

Extremities

Inspection and palpation of digits and nails

Skin

Inspection and/or palpation of skin an subcutaneous tissue

Neurological/Psychiatric

Brief assessment of mental status including: Orientation to time, place and person

Brief assessment of mental status including: Mood and affect

Ear, Nose, Mouth, and Throat Exam (97)

Constitutional

Measurement of any three vital signs

General appearance of patient

Assessment of ability to communicate

Head & Face

Inspection of head and face

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

External inspection of ears and nose

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

Inspection of pharyngeal walls and pyriform sinuses

Examination by mirror of larynx including the condition of the epiglottis, false vocal cords, true vocal cords and mobility of larynx

Examination by mirror of nasopharynx including appearance of the mucosa, adenoids, posterior choanae and Eustachian tubes

Neck

Examination of neck

Examination of thyroid

Respiratory

Inspection of chest including symmetry, expansion and/or assessment of respiratory effort

Auscultation of Auscultation of lungs

Cardiovascular

Auscultation of heart with notation of abnormal sounds and murmurs

Examination of peripheral vascular system by observation

Lymphatic

Palpation of lymph nodes in neck, axillae, groin and/or other location

Neurological/Psychiatric

Test cranial nerves with notation of any deficits

Brief assessment of mental status including: Orientation to time, place, and person

Mood and affect

Eye Exam (97)

Eyes

Test visual acuity

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 (e.g., ptosis or lagophthalmos), lacrimal glands, lacrimal drainage, orbits and preauricular lymph nodes)

Examination of pupils and irises including shape, direct/consensual reaction, size/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 exam of lenses incl. clarity, anterior and posterior capsule, cortex, and nucleus

Measurement of intraocular pressures

Opthalmoscopic exam of optic discs including size, C/D ratio, appearance, and nerve fiber layer

Opthalmoscopic exam of posterior segments including retina and vessels

Neuro/Psych

Brief assessment of mental status including orientation to time, place, and person

Brief assessment of mental status including mood and affect

Genitourinary Exam (97)

Constitutional

Measurement of any three vital signs

General appearance of patient

Neck

Examination of neck

Examination of thyroid

Respiratory

Assessment of respiratory effort

Auscultation of lungs

Cardiovascular

Auscultation of heart with notation of abnormal sounds and murmurs

Examination of peripheral vascular system by observation

Gastrointestinal

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 test when indicated

Genitourinary (Male)

Inspection of anus and perineum

Examination of genitalia including: Scrotum

Examination of genitalia including: Epididymides

Examination of genitalia including: Testes

Examination of genitalia including: Urethral meatus

Examination of genitalia including: Penis

Digital rectal examination including: Prostate gland

Digital rectal examination including: Seminal vesicles

Digital rectal examination including: Sphincter tone, presence of hemorrhoids, rectal masses

Genitourinary (Female)

Inspection and palpation of breasts

Digital rectal examination including sphincter tone, presence of hemorrhoids, rectal masses

Pelvic examination including: External genitalia

Pelvic examination including: Urethral meatus

Pelvic examination including: Urethra

Pelvic examination including: Bladder

Pelvic examination including: Vagina

Pelvic examination including: Cervix

Pelvic examination including: Uterus

Pelvic examination including: Adnexa/Parametria

Pelvic examination including: Anus and perineum

Lymphatic

Palpation of lymph nodes in neck, axillae, groin and/or other location

Skin

Inspection and/or palpation of skin and subcutaneous tissue

Neurological/Psychiatric

Brief assessment of mental status including: Orientation to time, place, and person

Brief assessment of mental status including: Mood and affect

Hematologic/Lymphatic/Immunologic Exam (97)

Constitutional

Measurement of any three vital signs

General appearance of patient

Head & 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

Neck

Examination of neck

Examination of thyroid

Respiratory

Assessment of respiratory effort

Auscultation of lungs

Cardiovascular

Auscultation of heart with notation of abnormal sounds and murmurs

Examination of peripheral vascular system by observation

Gastrointestinal

Examination of abdomen with notation of presence of masses or tenderness

Examination of liver and spleen

Lymphatic

Palpation of lymph nodes in neck, axillae, groin and/or other location

Extremities

Inspection and palpation of digits and nails

Skin

Inspection and/or palpation of skin an subcutaneous tissue

Neurological/Psychiatric

Brief assessment of mental status including: Orientation to time, place and person

Brief assessment of mental status including: Mood and affect

Musculoskeletal Exam (97)

Constitutional

Measurement of any three vital signs

General appearance of patient

Cardiovascular

Examination of peripheral vascular system by observation

Lymphatic

Palpation of lymph nodes in neck, axillae, groin and/or other location

Musculoskeletal

Examination of gait and station

Musculoskeletal - Head & Neck

Head & Neck - Inspection and/or palpation

Head & Neck - Assessment of range of motion

Head & Neck - Assessment of stability

Head & Neck - Assessment of muscle strength and tone

Musculoskeletal - Spine, Ribs, & Pelvis

Spine, Ribs, & Pelvis - Inspection and/or palpation

Spine, Ribs, & Pelvis - Assessment of range of motion

Spine, Ribs, & Pelvis - Assessment of stability

Spine, Ribs, & Pelvis - Assessment of muscle strength and tone

Musculoskeletal - Left Upper Extremity

Left Upper Extremity - Inspection and/or palpation

Left Upper Extremity - Assessment of range of motion

Left Upper Extremity - Assessment of stability

Left Upper Extremity - Assessment of muscle strength and tone

Musculoskeletal - Right Upper Extremity

Right Upper Extremity - Inspection and/or palpation

Right Upper Extremity - Assessment of range of motion

Right Upper Extremity - Assessment of stability

Right Upper Extremity - Assessment of muscle strength and tone

Musculoskeletal - Left Lower Extremity

Left Lower Extremity - Inspection and/or palpation

Left Lower Extremity - Assessment of range of motion

Left Lower Extremity - Assessment of stability

Left Lower Extremity - Assessment of muscle strength and tone

Musculoskeletal - Right Lower Extremity

Right Lower Extremity - Inspection and/or palpation

Right Lower Extremity - Assessment of range of motion

Right Lower Extremity - Assessment of stability

Right Lower Extremity - Assessment of muscle strength and tone

Skin

Head and neck - Inspection and/or palpation of skin and subcutaneous tissue

Trunk - Inspection and/or palpation of skin and subcutaneous tissue

Right Upper Extremity - Inspection and/or palpation of skin and subcutaneous tissue

Left Upper Extremity - Inspection and/or palpation of skin and subcutaneous tissue

Right lower extremity - Inspection and/or palpation of skin and subcutaneous tissue

Left lower extremity - Inspection and/or palpation of skin and subcutaneous tissue

Neurological/Psychiatric

Test coordination

Examination of deep tendon reflexes and/or nerve stretch test with notation of pathological reflexes

Examination of sensation

Brief assessment of mental status including: Orientation to time, place and person

Brief assessment of mental status including: Mood and affect

Neurological Exam (97)

Constitutional

Measurement of any three vital signs

General appearance of patient

Eyes

Ophthalmoscopic examination of optic discs and posterior segments

Cardiovascular

Examination of carotid arteries

Auscultation of heart

Examination of peripheral vascular system by observation and palpation

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 with notation of any atrophy or abnormal movements

Neurologc

Evaluation of higher integrative functions including: Orientation to time, place and person

Evaluation of higher integrative functions including: Recent and remote memory

Evaluation of higher integrative functions including: Attention span and concentration

Evaluation of higher integrative functions including: Language

Evaluation of higher integrative functions including: Fund of knowledge

Test of the 2nd cranial nerve

Test of the 3rd, 4th, and 6th cranial nerves

Test of the 5th cranial nerve

Test of the 7th cranial nerve

Test of the 8th cranial nerve

Test of the 9th cranial nerve

Test of the 11th cranial nerve

Test of the 12th cranial nerve

Examination of sensation

Examination of deep tendon reflexes in upper and lower extremities with notation of pathological reflexes

Test coordination

Psychiatric Exam (97)

Constitutional

Measurement of any three vital signs

General appearance of patient

Musculloskeletal

Assessment of muscle strength and tone with notation of any atrophy and abnormal movements

Examination of gait and station

Psychiatric

Description of speech including: rate; volume; articulation; coherence; and spontaneity with notation of abnormalities

Description of thought processes including: rate of thoughts; content of thoughts

Description of associations

Description of abnormal or psychotic thoughts including: hallucinations; delusions; preoccupation with violence; homicidal or suicidal ideation; and obsessions

Description of the patient's judgment and insight

Complete mental status examination including: Orientation to time, place and person

Complete mental status examination including: Recent and remote memory

Complete mental status examination including: Attention span and concentration

Complete mental status examination including: Language

Complete mental status examination including: Fund of knowledge

Complete mental status examination including: Mood and affect

Respiratory Exam (97)

Constitutional

Measurement of any three vital signs

General appearance of patient

Ears, Nose, Mouth, and Throat

Inspection of nasal mucosa, septum and turbinate's

Inspection of teeth, and gums

Examination of oropharynx: oral mucosa, salivary glands, hard and soft palates, tongue, tonsils, and posterior pharynx

Neck

Examination of Neck

Examination of Thyroid

Examination of jugular veins

Respiratory

Inspection of chest with notation of symmetry and expansion

Assessment of respiratory effort

Percussion of chest

Palpation of chest

Auscultation of lungs

Cardiovascular

Auscultation of heart including sounds, abnormal sounds and murmurs

Examination of peripheral vascular system by observation (

Gastrointestinal

Examination of abdomen with notation of presence of masses or tenderness

Examination of liver and spleen

Lymphatic

Palpation of lymph nodes in neck, axillae, groin and/or other location

Musculoskeletal

Assessment of muscle strength and tone with notation of any atrophy and abnormal movements

Examination of gait and station

Extremeties

Inspection and palpation of digits and nails

Skin

Inspection and/or Palpation of skin and subcutaneous tissue

Neurological/Psychiatric

Brief assessment of mental status including: Orientation to time, place and person

Brief assessment of mental status including: Mood and affect

Skin Exam (97)

Constitutional

Measurement of any three vital signs

General appearance of patient

Eyes

Inspection of conjunctivae and lids

Ears, Nose, Mouth, and Throat

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 Thyroid

Cardiovascular

Examination of peripheral vascular system by observation

Gastrointestinal

Examination of liver and spleen

Examination of anus for condyloma and other lesions

Lymphatic

Palpation of lymph nodes in neck, axillae, groin and/or other location

Extremeties

Inspection and palpation of digits and nails

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: Head and Face

Inspection and/or palpation of skin and subcutaneous tissue: Neck

Inspection and/or palpation of skin and subcutaneous tissue: Chest, including breasts and axillae

Inspection and/or palpation of skin and subcutaneous tissue: Abdomen

Inspection and/or palpation of skin and subcutaneous tissue: Genitalia, groin, and buttocks

Inspection and/or palpation of skin and subcutaneous tissue: Back

Inspection and/or palpation of skin and subcutaneous tissue: Right Upper Extremity

Inspection and/or palpation of skin and subcutaneous tissue: Left Upper Extremity

Inspection and/or palpation of skin and subcutaneous tissue: Right Lower Extremity

Inspection and/or palpation of skin and subcutaneous tissue: Left Lower Extremity

Inspection of eccrine and apocrine glands of skin and subcutaneous tissue with identification and location of any hyperhidrosis, chromhidroses or bromhidrosis

Neurological/Psychiatric

Brief assessment of mental status including: Orientation to time, place and person

Brief assessment of mental status including: Mood and affect

Diagnosis/Management Options

Self - Limited or Minor Problems

Established Diagnosis - Improving

Established Diagnosis - Worsening

New Problem - No Additional Work

New Problem - Additional Work

Amount/Complexity of Data

Review and/or order of clinical lab tests

Review and/or order X-Rays

Review and/or order other tests

Discussion of tests with performing MD

Independent review of image, tracing, or specimen

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

Review and summarize old records, obtain history from someone other than pt, discuss case with other MD

Risk

Presenting Problems

Minimal

One self-limited or minor problem

Low

Two or more self-limited or minor problems

One stable chronic illness

Acute uncomplicated illness or injury

Moderate

One or more chronic illness with mild exacerbation or progression

Two or more stable chronic illnesses

Undiagnosed new problem with uncertain prognosis

Acute illness with systemic symptoms

Acute complicated injury

High

One or more chronic illness with severe exacerbation or progression

Acute or chronic illness or injuries which pose a threat to life or bodily function

Abrupt change in Neurologic status

Diagnostic Procedures

Minimal

Lab tests requiring Venipuncture

Chest or other diagnostic X-ray

EKG/EEG

Urinalysis

Ultrasound

KOH prep

Low

Physiologic tests not under stress

Non-cardiovascular imaging studies with contrast

Superficial needle biopsies

Clinical laboratory tests requiring Arterial puncture

Skin biopsies

Moderate

Physiologic tests under stress

Deep needle or incisional biopsy

Diagnostic endoscopies with no identified risk factors

Cardiovascular imaging studies with contrast and no identified risk factors

Obtain fluid from body cavity

High

Cardiovascular imaging studies with contrast with identified risk factors

Cardiac Electrophysiological tests

Diagnostic endoscopies with identified risk factors

Discography

Management Options

Minimal

Rest

Gargles

Elastic bandages

Superficial dressings

Low

Over-the-counter drugs

Minor surgery with no identified risk factors

Physical therapy

Occupational therapy

IV fluids without additives

Moderate

Minor surgery with identified risk factors

Elective major surgery with no risk factors

Prescriptions drug management

Therapeutic nuclear medicine

IV fluids with additives

Closed treatment of fracture or dislocations without manipulation

High

Elective major surgery with identified risk factors

Emergency major surgery

Parenteral controlled substances

Drug therapy requiring intensive monitoring for toxicity

Decision not to resuscitate or to de-escalate care because of poor prognosis

Time

None

Face to Face

Unit/Floor

Duration

Clear

Audit Results

HPI Level:
ROS Level:
PFSH Level:
History Level:

Exam Level:

Diag. Op. Level:
Complexity Level:
Risk Level:
MDM Level:

CPT Code:

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