Effective January 1, 2023, this information is no longer up-to-date. The material on this page covers only the 1995 and 1997 E/M guidelines and is no longer accurate. A new set of E/M guidelines was released in 2021, with some minor modifcations added for 2023. These new guidelines are now used to document all encounters in both the outpatient and inpatient settings. For the most recent E/M coding guidance, visit our home page here.
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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 clinical example, the History, Physical Exam and Medical Decision-Making all make the grade easily
History
This Problem Focused History in the clinical example requires only a chief complaint and a brief HPI (one to three HPI elements). In this case two HPI elements were actually used: context (hit in arm while playing tennis) and location (left arm). Notice that no ROS or PFSH are required.
Physical Exam
Using the 1997 E/M guidelines, the example qualifies as a Problem Focused Exam, which requires only 1 -5 bullets. Two bullets were utilized here:
- Examination of joints, bones and muscles of the left upper extremity
- Inspection of skin and subcutaneous tissue
Medical Decision-Making
The cognitive labor required for the 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.
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 = 1
In the example, the presence of one “self-limited or minor problem” of a simple arm .
contusion adds up to one problem poin .
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
equires ONEof 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
|
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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 |
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| 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 : Quite frankly, this is the kind of encounter during which one has to spend a significant amount of time trying to figure out the reason for the consult. The acuity of care is exceedingly low. It’s hard to believe that internists selected this code for 15,246 encounters in 2003.
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