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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. It is important to remember that the elements used to complete the history and physical need to be driven by the intrinsic medical necessity of the encounter.
History
This example qualifies as a Detailed History which requires a chief complaint, an extended HPI consisting of four HPI elements, an extended ROS (review of two to nine systems), plus a pertinent PFSH (which requires at least ONE element from ANY component of PFSH). In the above example, the status of three chronic or inactive problems (diabetes, osteoarthritis, “borderline” hypertension) was used to qualify for an extended HPI. The documentation of well heavy alcohol consumption satisfies the requirement for ONE element of PFSH. A clinically appropriate review of three systems which may have bearing on the diagnosis or treatment of the presenting problem (musculoskeletal, endocrine and GI) fulfills the requirement for an extended ROS.
Physical Exam
Using the 1997 E/M guidelines, the example qualifies as a Detailed Physical Exam which requires a total of 12 bullets from any systems. The example contains at least the following 13 bullets, all of which are clinically informative :
- General appearance
- Three vital signs
- Examination of neck
- Examination of thyroid
- Examination of the carotid arteries
- Auscultation of heart
- Auscultation of lungs
- Examination of the abdomen with notation of presence of masses or tenderness
- Examination of the liver and spleen
- Examination of abdominal aorta
- Examination of the pedal pulses
- Assessment of lower extremities for edema and/or varicosities
- Inspection and/or palpation of digits and nails
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 expended and the acuity of care are both minimal:
Straightforward 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 = 2
The presence of sub-optimally controlled DM2 scores two problem points.
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 = 1
One data point is scored for ordering routine labs .
Risk
A review of the table of risk shows that this encounter has Moderate Risk due to the presenting problems of “one or more chronic illness, with mild exacerbation” OR for the management option of “prescription drug management.” |
| 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 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
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, two problem points, one data point and Moderate Risk add up to Low Complexity Medical Decision-Making .
E/M University Coding Tip : The extent of the history and physical exam should always be directed by the intrinsic medical necessity of the encounter. The history and physical exam should be applied in a probative and informative manner to provide an economy of information about the presenting clinical problems identified by the chief complaint and the HPI. There is no need to document more than is necessary to address the clinical problems.
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