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For this type of encounter only two 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 Problem Focused History which requires only a chief complaint and a brief HPI (one to three HPI elements). In this case only one HPI elements was used: location (right hip). Notice that no ROS or PFSH are required.
Physical Exam
Using the 1997 E/M guidelines, the example DOES qualify as a Problem Focused Exam, which requires the documentation of only 1 -5 bullets. The following four bullets were utilized:
- General appearance
- Three vital signs
- Auscultation of lungs
- Auscultation of the heart
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 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 = 2
In the example, the presence of the two established and stable problems of hypertension and osteoarthritis adds up to a total of two problem points.
Data Points
The data points for the clinical example 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 the clinical example qualifies as Low Risk due to the management option selected of PT/OT. |
| 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 |
|
| In this case, all three components of Medical Decision-Making point toward Low Complexity Medical Decision-Making. |
E/M University Coding Tip : It is difficult to believe that this E/M code ranks 6th overall among all CPT codes. In 2003, a total of 6,144,866 of these visits were reported. The history, exam, and cognitive labor are so miniscule one cannot help but wonder why these patients would even be in the hospital at all. It is likely that this code is being OVER-utilized and that a significant percentage of physicians are therefore undercoding on a monumental scale .
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