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You see an established office patient with hypertension, diabetes and a history of dyslipidemia
You look over your note from an earlier encounter and remember the patiet has hypertension, diabetes and dyslipidemia. After a brief discussion with the patient and a review of the vital signs and labs, it becomes apparent that all three problems are well controlled. The patient is tolerating all medications without any significant problems so you will not need to make any changes in the patient's prescriptions.
How would you document and code for this encounter?
Rational Physician Coding requires that the physician answer four questions
- What is the level of Medical Decision-Making?
- What is the "target code?"
- What documentation is required?
- Is it reasonable and medically necessary to do what the documentation asks?
Step 1: What is the level of Medical-Decision-Making required?
Before you begin your documentation, Rational Physician Coding directs you to calculate the Medical Decision-Making first in order to establish a target E/M code for the encounter. This is best done in a systematic manner by considering each component of the medical deicison-making independently using the medical decision-making point system.
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 |
|
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Total Problem Points = 3
The three established and stable problems of hypertension, diabetes and dyslipidemia are added up individually for a total of three problem points.
Data Points
The data points for the 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 = 1
This encounter rates only one data point for review of labs. Notice that you DO NOT get an additional data point for also ordering labs. No double dipping is allowed!
Risk
A review of the table of risk shows that this encounter qualifies as being of Moderate Risk due to the presenting problems of “two or more stable chronic illnesses.” . |
| 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
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- 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, three problem points, one data point and Moderate Risk add up to Moderate Complexity Medical Decision-Making.
Step 2 : What is the target code?
Now that you know that the cognitive labor required for this encounter corresponds to Moderate Complexity Medical Decision-Making, the next step in Rational Physician Coding is to identify the appropriate "target code". The target code is the level of care which matches the intensity of Medical Decision-Making for that type of ecnounter. A review of any standard E/M reference card for "established office patients" reveals that Moderate Medical Decision-Making corresponds to the 99214 level of care. Therefore the 99214 is the target code for this encounter based on the objective parameters of the Medical Decision-Making. |
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For these encounters, documentation of two out of three key components is required for any given level of care
The target code is highlighted in green. This is the level of care which matches Moderate Complexity Medical Decision-Making (highlighted in yellow) for an established office patient.
Step 3: What documentation is required?
The documentation requirements for the 99214 target code are highlighted in blue. Note that for this particular type of encounter, only two out of three qualifying key components must be present and documented in order to satisfy the requirements for any given level of care. Since you already know that the Medical Decision-Making is going to be one of your qualifying key components, it is only necessary to fully document EITHER a Detailed Exam or a Detailed History.
Step 4: Is it reasonable and medically necessary to do what the documentation asks?
In this case you decide it would be "overkill" do perform and document the exam, but it is well within the bounds of medical necessity to perform and document a Detailed History.
Here's how the finished product would look :
CC : Follow-up hypertension and diabetes
Interval History : The patient’s hypertension has been well controlled on current medications. Diabetes is stable as well, with no significant hyperglycemia or episodes of symptomatic hypoglycemia. Dyslipidemia remains well controlled on statin therapy.
Medications
Lisinopril 20 mg po qd
Atorvastatin 10 mg po qd
Glyburide 10 mg po bid
ROS : General--Negative for fatigue, weight loss, anorexia
Cardiovascular--Negative for chest pain, orthopnea or PND
Neurologic-- Negative for paresthesias
Pertinent PFSH is remarkable for mild OA which has been quiescent
Physical Exam
General: NAD, conversant
Vitals: 120/80, 65, 98.6
HEENT: No JVD or carotid bruits
Lungs: CTA
CV: RRR
Extremities: No peripheral edema
Labs: BUN 12, creatinine 0.8, HGBA1C 6.8, spot microalbumin/creatinine ration is 28 mcg/g; LDL 77
Assessment
- Well controlled Type 2 NIRDM
- Well controlled hypertension
- Stable dyslipidemia
Plan
- Continue current medications unchanged
- Repeat renal profile, spot microalbumin/creatinine at next visit, along with cbc
- Check LFTs at next visit as well due to ongoing statin therapy
- Continue lifestyle modifications and exercise for weight loss
- Return visit in four months
For a detailed breakdown of this note with tips and advice see 99214 E/M Insight
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