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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. It is important to remember that the elements used to complete the history and physical need to be driven by the intrinsic medical necessity of the encounter.
History
The example qualifies as a Detailed History which requires a chief complaint, an extended HPI consisting of four HPI elements, an extended ROS (review of two to nine systems), plus a pertinent PFSH (which requires at least ONE element from ANY component of PFSH). In the above example, four HPI elements were used: location (knees), duration (six months), quality (dull ache) and modifying factors (worse after walking). The documentation of well controlled hypertension satisfies the requirement for ONE element of PFSH. A clinically appropriate review of three systems which may have bearing on the diagnosis or treatment of the presenting problem (musculoskeletal, gastrointestinal, and neurologic) fulfills the requirement for an extended ROS. The systems reviewed are probative for diagnostic purposes (musculoskeletal and neurologic) or for possible therapeutic reasons (gastrointestinal system is reviewed to evaluate the patient’s suitability for NSAID medication).
Physical Exam
Using the 1997 E/M guidelines, the example qualifies as a Detailed Physical Exam which requires a total of 12 bullets from any systems. The example contains at least the following 14 bullets, all of which are clinically informative:
- General appearance
- Three vital signs
- Auscultation of heart
- Examination of the abdomen with notation of presence of masses or tenderness
- Examination of the pedal pulses (e.g., pulse amplitude)
- Examination of gait and station
- Inspection and/or palpation (knees) with notation of presence of any misalignment, asymmetry, crepitation, defects, tenderness, masses or effusions
- Assessment of range of motion (knees) with notation of any pain, crepitation or contracture
- Assessment of stability (knees) with notation of any dislocation, subluxation, or laxity
- Assessment of muscle strength and tone (both lower extremities) with notation of any atrophy or abnormal movements
- Assessment of lower extremities for edema and/or varicosities
- Inspection and/or palpation of digits and nails
- Inspection of skin and subcutaneous tissue (e.g., rashes, lesions, ulcers)
- Palpation of the skin and subcutaneous tissue (temperature and turgor)
Medical Decision-Making
The cognitive labor required for the clinical example satisfies the requirements for Low Complexity Medical Decision-Making. Note that the intellectual energy required and the acuity of care are both fairly 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 = 4
The presence of probable osteoarthritis constitutes a “new problem, with additional work-up planned”. In this case the additional work-up consists of x-rays ordered .
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 = 2
One data point is scored for ordering routine follow-up labs (after starting chronic NSAID therapy). An additional data point is scored for ordering “plain films” of both knees.
Risk
Review of the table of risk shows that this encounter qualifies as Low Risk due to the management option of “over-the-counter drugs” OR for referral to “occupational therapy” and “physical therapy” |
| Risk
Level |
Presenting
Problems |
Diagnostic
Procedures |
Management Options
Selected |
| Minimal Risk
equires ONEof these elements in ANY of the three categories listed |
- Two or more self-limited or minor problems
- One stable chronic illness, e.g., well controlled HTN, DM2, cataract
- Acute uncomplicated injury or illness, e.g., cystitis, allergic rhinitis, sprain
|
- Physiologic tests not under stress, e.g., PFTs
- Non-cardiovascular imaging studies with contrast, e.g., barium enema
- Superficial needle biopsy
- ABG
- Skin biopsies
|
- Over the counter drugs
- Minor surgery, with no identified risk factors
- Physical therapy
- Occupational therapy
- IV fluids, without additives
|
|
| 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 |
|
| Since two out of three factors must meet or exceed the requirements for any given level of Medical Decision-Making, four problem points, two data points and Low Risk add up to Low Complexity Medical Decision-Making. |
E/M University Coding Tip : The extent of the history and physical exam should always be directed by the intrinsic medical necessity of the encounter. It is NOT acceptable to use a “shotgun” approach and simply perform a Comprehensive History and Comprehensive Physical Exam on every patient with the sole purpose of qualifying for a higher paying level of care. The history and physical exam may be viewed as medical procedures, which should be performed only when medically indicated. Don’t clutter up the medical record with boilerplate and useless blather. The history and physical exam should be applied in a probative and informative manner to provide an economy of information about the presenting clinical problems identified by the chief complaint and the HPI .
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