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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 easily
History
The example qualifies as a Comprehensive History which requires a chief complaint, an extended HPI consisting of four HPI elements (or the status of three chronic or inactive problems—if using the 1997 guidelines), a complete ROS (which requires at least 10 systems), and a complete PFSH (which in this case requires at least ONE element from each PFSH category). In the above example, the requirements for the HPI are met by commenting on the status of three chronic or inactive problems (hypertension, dyslipidemia and osteoarthritis). The PFSH elements used are self-explanatory. Note that at least ONE element from EACH category of PFSH is present. The ROS requirements were fulfilled by commenting on pertinent findings and using a form to document the complete ROS. Notice that the date and location of the ROS form are clearly recorded in the chart.
Physical Exam
Using the 1997 E/M guidelines, the clinical example qualifies as a Comprehensive Physical Exam which requires two bullets in EACH of nine organ systems. The following bullets and systems were used:
Constitutional
- 3 vital signs
- general appearance
Eyes
- inspection of conjunctiva and lids
- examination of pupils and irises (PERRLA)
- ophthalmoscopic discs and posterior segments
Ears, Nose, Mouth, and Throat
- external appearance of the ears and nose (NC/AT)
- examination of oropharynx:
Neck
- examination of neck (e.g., masses, symmetry, tracheal position)
- examination of thyroid
Respiratory
- assessment of respiratory effort (e.g., intercostal retractions)
- auscultation of the lungs
Cardiovascular
- auscultation of the heart with notation of abnormal sounds and murmurs
- examination of the carotid arteries (e.g., pulse amplitude, bruits)
- assessment of lower extremities for edema and/or varicosities
Gastrointestinal (Abdomen)
- examination of the abdomen with notation of presence of masses or tenderness
- examination of the liver and spleen
Lymphatic (palpation of lymph nodes two or more areas)
Skin
- inspection of skin and subcutaneous tissue (e.g., rashes, lesions, ulcers)
- palpation of the skin and subcutaneous tissue (temperature and turgor)
Psychiatric
- orientation to time, place, and person
- mood and affect
A total of 10 systems with at least two bullets each were included, even though the requirement is only for nine systems with two bullets each.
Medical Decision-Making
The cognitive labor required for the clinical example satisfies the requirements for Moderate Complexity Medical Decision-Making. Note that the intellectual energy required and the acuity of care remain fairly routine.
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 = 10
The new problems of proteinuria and renal insufficiency which require further work-up are worth four points each. The established, but not controlled problem of hypertension is worth two points. Once can argue that the proteinuria is related to the renal disease so these problems should not be recorded separately. These semantic arguments are rendered moot by the fact that the maximum amount of points required for the highest level of medical decision making is four, so who cares?
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
This encounter rates two data points for ordering/reviewing labs and ordering a renal ultrasound
Risk
A review of the table of risk shows that this encounter has Moderate Risk written all over it due to the presenting problems of “one or more chronic illness, with mild exacerbation” OR “two or more stable chronic illnesses” OR for the management option of “prescription drug management.” |
| Risk
Level |
Presenting
Problems |
Diagnostic
Procedures |
Management Options
Selected |
| Minimal Risk
equires ONEof these elements in ANY of the three categories listed |
- One or more chronic illness, with mild exacerbation, progression, or side effects of treatment
- Two or more stable chronic illnesses
- Undiagnosed new problem, with uncertain prognosis, e.g., lump in breast
- Acute illness, with systemic symptoms
- Acute complicated injury, e.g., head injury, with brief loss of consciousness
|
- Physiologic tests under stress, e.g., cardiac stress test, fetal contraction stress test
- Diagnostic endoscopies, with no identified risk factors
- Deep needle, or incisional biopsies
- Cardiovascular imaging studies, with contrast, with no identified risk factors, e.g., arteriogram, cardiac catheterization
- Obtain fluid from body cavity, e.g., LP/thoracentesis
|
- Minor surgery, with identified risk factors
- Elective major surgery (open, percutaneous, or endoscopic), with no identified risk factors
- Prescription drug management
- Therapeutic nuclear medicine
- IV fluids, with additives
- Closed treatment of fracture or dislocation, without manipulation
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| 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 : When seeing a patient for any type of initial encounter (such as a consult), the Problem Points add up quickly. Usually, the ultimate level of Medical Decision-Making is therefore determined by the extent of the data reviewed and the level of risk
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