For this type of encounter three out of three key components must satisfy the documentation requirements for any particular level of care. In the clinical example, the History, Physical Exam and Medical Decision-Making all make the grade easily
History
This clinical example qualifies as an Expanded Problem Focused History which requires a chief complaint, a brief HPI consisting of one to three HPI elements, plus a single ROS. No PFSH elements are required. In the above example, five HPI elements are used: context (spider bite while cleaning a shed), location (left thumb) and duration (yesterday), severity (really, really painful) and associated signs and symptoms (redness and swelling). Review of the cardiovascular and pulmonary systems in more than adequate to satisfy the single ROS requiremen t.
Physical Exam
Using the 1997 E/M guidelines, the example satisfies the requirements for an Expanded Problem Focused Exam, which requires a total of six bullets from any organ systems. The following seven bullets were utilized::
- General appearance
- Three vital signs
- Auscultation of lungs
- Auscultation of the heart with notation of abnormal sounds and murmurs
- Assessment of lower extremities for edema and/or varicosities
- Inspection and/or palpation of digits and nails
- Inspection of skin and subcutaneous tissue
Medical Decision-Making
The cognitive labor required for the above example DOES satisfy the requirements for Straightforward Complexity Medical Decision-Making. Note that the intellectual energy required and the acuity of care are both very minimal.
Moderate Complexity Medical Decision-Making requires TWO out of THREE of the following :
Problem Points
In the example above, the clinical problems would be scored as follows : |
| Problems |
Points |
Example |
| Self-limited or minor (maximum of 2) |
1 |
 |
| Established problem, stable or improving |
1 |
|
| Established problem, worsening |
2 |
|
| New problem, with no additional work-up planned (maximum of 1) |
3 |
|
| New problem, with additional work-up planned |
4 |
|
|
Total Problem Points = 1
I
In the example, the presence of one “self-limited or minor problem” of the spider bite adds
up to one problem point..
Data Points
The data points for the above encounter are scored as follows : |
| Data
Reviewed
|
Points |
Example |
| Review or order
clinical lab tests |
1 |
|
| Review or order
radiology test (except heart catheterization or echo) |
1 |
|
| Review or order
medicine test (PFTs, EKG, cardiac echo or cath) |
1 |
|
| Discuss test
with performing physician |
1 |
|
| Independent
review of image, tracing, or specimen |
2 |
|
| Decision to
obtain old records |
1 |
|
| Review and
summation of old records |
2 |
|
|
Total Data Points = 0
No points were garnered for review of data .
Risk
Review of the table of risk shows that this encounter qualifies as Minimal Risk due to the
management option of “superficial dressings.” |
| Risk
Level |
Presenting
Problems |
Diagnostic
Procedures |
Management Options
Selected |
| Minimal Risk
equires ONEof these elements in ANY of the three categories listed |
One self-limited or minor problem, e.g., cold, insect bite, tinea corporis |
- Laboratory tests
- Chest X-rays
- EKG/EEG
- Urinalysis
- Ultrasound/Echocardiogram
- KOH prep
|
- Rest
- Gargles
- Elastic bandages
- Superficial dressings
|
|
| Given the above information, the MDM Points table would look like this : |
| Overall MDM
|
Problem Points |
Data Reviewed Points |
Risk |
| Straightforward Complexity |
1 |
1 |
Minimal |
| Low complexity |
2 |
2 |
Low |
| Moderate Complexity |
3 |
3 |
Moderate |
| High Complexity |
4 |
4 |
High |
|
| In this case, all three components of Medical Decision-Making point toward Straightforward Complexity. This is the lowest possible level of Medical Decision-Making so it is impossible NOT to qualify for it. |
E/M University Coding Tip : It’s interesting to note that the 99242 code requires the exact same level of Medical Decision-Making as the lower paying 99241 code. The only rational reason to use the 99241 code instead of the 99242 would be when the clinical circumstances of the encounter do not support the slightly more detailed history (in this case the addition of one ROS) and the slightly more intensive physical exam (six bullets as opposed to one to five bullets) which are required for the 99242.
|
