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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 our 99214 clinical example, the History and Medical Decision-Making make the grade, while the Physical Exam falls well short, but that's okay because we don't need all three key components to qualify for this level of care. In this type of situation, it is up to the individual physician to decide which elements to document. Note that the amount of documentation required remains fairly modest. Physicians often tend to OVERDOCUMENT the 99214.
History
This clinical example qualifies as a Detailed History which requires a chief complaint, an extended HPI consisting of four HPI elements (or the status of three chronic problems--if using the 1997 guidelines), 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 problems (hypertension, diabetes and dyslipidemia) was used to satisfy the HPI requirements using the 1997 E/M rules. A review of the constitutional, cardiovascular, and neurologic systems satisfied the requirement for two to nine ROS. Notice that a total of two PFSH elements were used (one for PMH of OA and one for list of current medications), although only one PFSH element is actually required.
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. Note that 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 six bullets:
- General appearance defects, tenderness, masses or effusions
- Three vital signs
- Examination of the carotid arteries (e.g., pulse amplitude, bruits)
- Auscultation of the heart with notation of abnormal sounds and murmurs
- Auscultation of lungs
- Assessment of lower extremities for edema and/or varicosities
Medical Decision-Making
The cognitive labor required for the clnical example satisfies the requirements for Moderate Complexity Medical Decision-Making. Note that, although multiple clinical issues are addressed, the acuity of care remains fairly routine. No dramatic changes are made to the course of treatment, but this does NOT diminish the complexity of dealing with multiple interlocking diagnoses.
Moderate Complexity 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 = 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 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
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
|
- 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. |
E/M University Coding Tip : As noted above, the 99214 is the second most common CPT code used by all physicians combined. It is second only to the 99213. The 99214 was charged a total of 49,912,657 times in 2003. However, despite these impressive numbers we believe that the 99214 remains the most inappropriately UNDER-utilized code in the book. This level of care requires only Moderate Complexity Medical Decision-Making. If you objectively review the requirements for this level of cognitive labor, you will probably agree it seems congruent with the clinical circumstances of most “routine” encounters. But for some reason, physicians tend to use the 99213 code to charge for encounters they perceive as being “routine” even though the 99214 would be a better fit. The take-home message is simple: “Routine” does not always equal “Low Complexity” when it comes to Medical Decision-Making. If you take the time to systematically quantify the Medical Decision-Making by utilizing the MDM Points System, you can avoid this form of chronic undercoding.
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