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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 and Medical Decision-Making make the grade, while the Physical Exam falls just short. This example illustrates the fact that, for encounters requiring documentation of only two out of three key components, it is up to the individual physician to decide which elements to document. Physicians should let the documentation be driven by the clinical circumstances of the encounter.
History
The clinical example qualifies as a Detailed History. Usually this level of history must include one element of PFSH, but this requirement is waived for hospital progress notes . Therefore in this case a Detailed History requires only a chief complaint, an extended HPI consisting of four HPI elements (or the status of three chronic problems--if using the 1997 guidelines) and an extended ROS (review of two to nine systems). In the example, the status of three problems (ARF, CAD and hypertension) are used to satisfy the HPI requirements using the 1997 E/M rules. A review of the constitutional, cardiovascular, and GU systems satisfy the requirement for two to nine ROS. All the elements of history included are probative and clinically relevant in keeping with the intrinsic medical necessity of the encounter. Notice that even though no PFSH is required for this particular Detailed History, a review of the patient’s medications would technically count as one element of PFSH .
Physical Exam
Using the 1997 E/M guidelines, the clinical example does NOT qualify as a Detailed Exam. This level of exam would require documentation of at least of 12 bullets from any organ systems. The documentation is still compliant with the E/M guidelines for this level of care because this type of encounter requires documentation of only two out of three qualifying key components. (In this case the History and Medical Decision-Making both qualify). The physical exam in the example qualifies only as an Expanded Problem Focused Exam because it utilizes just the following 11 clinically relevant bullets :
- General appearance
- Three vital signs
- Examination of oropharynx
- Auscultation of the heart with notation of abnormal sounds and murmurs
- Auscultation of lungs
- 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)
- Orientation to time, place, and person
- Mood and affect
Medical Decision-Making
The cognitive labor required for the clinical example satisfies the requirements for High Complexity Medical Decision-Making. Note that the patient is not critically ill, but has a confluence of slowly worsening clinical problems which can affect morbidity and mortality.
High Complexity Medical Decision-Making requires TWO out of THREE of the following :
Problem Points
For the clinical example , the problem points are 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 = 8
Two points EACH are scored for the established, but worsening problems of acute renal failure, cardiomyopathy, hypertension and anemia, which adds up to a total of eight points. One could argue that points should also be scored for metabolic acidosis and hyperkalemia, but since the maximum points needed for High Complexity Medical Decision-Making is four, this is a moot question.
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 garnered for reviewing/ordering labs and one point for ordering a chest X-ray
Risk
A review of the table of risk shows that this encounter qualifies as being of High Risk due to the presenting problems of “one or more chronic illness with severe exacerbation or progression.” (Cardiomyopathy) OR “Acute or chronic illness…posing a threat to life of bodily function.” (ARF) |
| Risk
Level |
Presenting
Problems |
Diagnostic
Procedures |
Management Options
Selected |
Minimal Risk
Requires ONE of these elements in ANY of the three
categories listed |
- One or more chronic illness, with severe exacerbation or progression
- Acute or chronic illness or injury, which poses a threat to life or bodily function, e.g., multiple trauma, acute MI, pulmonary embolism, severe respiratory distress, progressive severe rheumatoid arthritis, psychiatric illness, with potential threat to self or others, peritonitis, ARF
- An abrupt change in neurological status, e.g., seizure, TIA, weakness, sensory loss
|
- Cardiovascular imaging, with contrast, with identified risk factors
- Cardiac EP studies
- Diagnostic endoscopies, with identified risk factors
- Discography
|
- Elective major surgery (open, percutaneous, endoscopic), with identified risk factors
- Emergency major surgery (open, percutaneous, endoscopic)
- Parenteral controlled substances
- Drug therapy requiring intensive monitoring for toxicity
- Decision not to resuscitate, or to de-escalate care because of poor prognosis
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| Given the above information, the MDM points table would look like this: |
| Overall MDM
|
Problem
Points
|
Data
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, eight problem points, two data points and High Risk add up to High Complexity Medical Decision-Making .
E/M University Coding Tip : The 99233 should probably be used more often by all physicians. In the above example, High Risk is obvious and is used as a qualifying component of High Complexity Medical Decision-Making, but it is not necessary that every patient assigned this code be High Risk. Often, the Data Points can add up quickly in the hospital (especially if you personally review an image or tracing). In these cases the Data Points can be added to the Problem Points to qualify for High Complexity Medical Decision-Making. Physicians are urged to systematically calculate the Medical Decision-Making for every encounter in order to recognize and take credit for their cognitive labor.
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