SAMPLE E/M CODING TEMPLATE

Sample 1			Sample 3
HPI (list the elements)			HPI (list the elements)
ROS			ROS
PFSH			PFSH
History level			History level
No. of systems in Exam			No. of systems in Exam
Exam Level			Exam Level
MDM-Table A			MDM-Table A
MDM-Table B			MDM-Table B
MDM-Table C			MDM-Table C
Overall MDM			Overall MDM
E&M Level			E&M Level
Modifier (if any)			Modifier (if any)
DX			DX

Sample 2			Sample 4
HPI (list the elements)			HPI (list the elements)
ROS			ROS
PFSH			PFSH
History level			History level
No. of systems in Exam			No. of systems in Exam
Exam Level			Exam Level
MDM-Table A			MDM-Table A
MDM-Table B			MDM-Table B
MDM-Table C			MDM-Table C
Overall MDM			Overall MDM
E&M Level			E&M Level
Modifier (if any)			Modifier (if any)
DX			DX

Sample 5
HPI (list the elements)
ROS
PFSH
History level
No. of systems in Exam
Exam Level
MDM-Table A
MDM-Table B
MDM-Table C
Overall MDM
E&M Level
Modifier (if any)
DX