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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 example above, 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 (diabetes, COPD and hypertension) The PFSH elements used are self-explanatory and clinically relevant. Note that at least ONE element from EACH category of PFSH is present. The ROS requirements were fulfilled by commenting on pertinent findings and making use of the accepted ROS shorthand of “all others negative.” .
Physical Exam
Using the 1997 E/M guidelines, this 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
Notice that 26 bullets in 10 systems are utilized, even though this is more than is needed for E/M compliance. This reflects the fact that a conscientious exam often includes more elements than required by the E/M guidelines.
Medical Decision-Making
The cognitive labor required for the above example satisfies the requirements for High Complexity Medical Decision-Making. Note that the patient is not critically ill, but has multiple chronic and progressive medical problems. In addition, a significant amount of data was addressed by the physician.
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 = 6
Four points are scored for the new problem of possible CHF which requires additional work-up. One point each is scored for the two established and stable problems of diabetes and hypertension. Note that even though the diabetes and hypertension are not addressed specifically in the plan, they are still included in tallying the problem points because their presence significantly impacts the treatment and prognosis of the patient’s suspected cardiomyopahy.
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 = 5
Two data points are scored because the physician personally reviewed the EKG tracing and recorded the findings in the chart. Review of the X-ray report and lab work count as one point each. Finally one point is garnered for ordering the echocardiogram.
Risk
A review of the table of risk shows the clinical example easily qualifies as being of Moderate Risk due to the presenting problems of “one undiagnosed new problem with uncertain prognosis” OR the diagnostic procedure ordered of “physiologic tests under stress” OR for the management option selected of “prescription drug management.” One can argue that the encounter could be categorized as High Risk due to the presenting problem of new onset CHF which may represent “an acute or chronic illness that poses a threat to life or bodily function.” |
| 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 only two out of three factors must meet or exceed the requirements for any given level of Medical Decision-Making, six problem points, five data points and Moderate Risk add up to High Complexity Medical Decision-Making. |
E/M University Coding Tip : Often the patient does not have to be in medical extremis to justify billing the highest level of care. Even in cases where High Risk is not present, the MDM may still qualify as High Complexity on the basis of the problem points and data points. (Remember, it only takes two out of three elements of MDM to qualify for any given level of complexity.) This situation comes up most frequently during “new” encounters (consults, H&Ps, and new office patients) when the data points often represent the “low hanging fruit” of the MDM process. Physicians often fail to give themselves credit for their cognitive labor by neglecting to factor in the data points when calculating the MDM. This can lead to systematic undercoding.
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