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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 short.
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 = 5
Two points EACH are scored for the established, but worsening problems of CHF and hypertension, which adds up to a four points. One point is also garnered for the resolving hypokalemia (which is still being treated with the potassium repletion protocol).
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 = 4
One data point is garnered for reviewing/ordering labs and one point for ordering a chest X-ray. Two points are counted for personally reviewing the CXR.
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 or more chronic illness with mild exacerbation or due to “prescription drug management.” One can argue that the encounter could be categorized as High Risk due to the presenting problem of "severe exaceration" of 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
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 only two out of three factors must meet or exceed the requirements for any given level of Medical Decision-Making, five problem points, four data points and Moderate Risk add up to High Complexity Medical Decision-Making .
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