1. Evaluation and Management: An Overview
2. History of Present Illness (HPI)
3. Review of Systems (ROS)
4. Past, Family, Social History (PFSH)
5. Selecting the Overall History Level: Putting HPI, ROS, and PFSH Together
6. Physical Examination: The 1995 Physical Exam
7. Physical Examination: The 1997 General Multi System Physical Exam
8. Physical Examination: The 1997 Single Organ System Physical Exam
9. Medical Decision Making: Number of Diagnosis and/or Management Options
10. Medical Decision Making: Complexity of Data Reviewed
11. Medical Decision Making: The Risk of Complication, Morbidity, or Mortality
12. Selecting the Overall Medical Decision Making Level
13. Putting All the Elements Together to Find the Right E/M Code
14. Evaluation and Management Guidelines: Categories Requiring Content of Service
15. Evaluation and Management Guidelines: Case Management, Care Plan Oversight, Preventive Medicine, Non-Face-to-Face Physician Services, Domiciliary or Home Care Plan Oversight, and Special Services
16. Evaluation and Management Guidelines: Categories Requiring Something More: Prolonged Services, Newborn Care, and Critical Care
17. Evaluation and Management Modifiers
18. Evaluation and Management Resources and Summary
APPENDIX A: Instructions for Accessing the 1995 Documentation Guidelines for Evaluation and Management Services
APPENDIX B: Instructions for Accessing the 1997 Documentation Guidelines for Evaluation and Management Services
APPENDIX C: The Anatomy of the Evaluation and Management Medical Documentation
