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 easily.
History
The clinical 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 three HPI elements were actually used: context (after a bee sting, while gardening), location (index finger) and severity (quite). Notice that no ROS or PFSH are required.
Physical Exam
Using the 1997 E/M guidelines, the clinical example qualifies as a Problem Focused Exam, which requires only 1 -5 bullets. Two bullets were utilized here:
- Inspection and/or palpation of digits and nails
- Inspection of skin and subcutaneous tissue
Medical Decision-Making
The cognitive labor required for the clinical example DOES satisfy the requirements for Straightforward Complexity Medical Decision-Making. Note that the intellectual energy required and the acuity of care are both very minimal.
Straightforward 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 = 1
In the example, the presence of one “self-limited or minor problem” of a simple bee sting adds up to one problem point.
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 = 0 No points were garnered for review of data.
Risk
Review of the table of risk shows that this encounter qualifies as Minimal Risk due to the presenting problem of “one self-limited or minor problem.” |
| Risk
Level |
Presenting
Problems |
Diagnostic
Procedures |
Management Options
Selected |
Minimal Risk
Requires ONE of these elements in ANY of the three
categories listed |
One self-limited or minor problem, e.g.,
cold, insect bite, tinea corporis |
Laboratory
tests
Chest
X-rays
EKG/EEG
Urinalysis
Ultrasound/Echocardiogram
KOH
prep
|
- Rest
- Gargles
- Elastic
bandages
- Superficial
dressings
|
|
| Given the above information, the MDM Points table would look like
this:
|
|
In this case, all three components of MDM point toward Straightforward Complexity. This is the lowest possible level of Medical Decision-Making so it is impossible NOT to qualify for it.
E/M University Coding Tip : It’s hard to believe that a person would seek medical attention for this type of self-limited problem, but apparently it does happen. Family practitioners used this code an astonishing 49,281 times in 2003.
|
