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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, Physical Exam, and Medical Decision-Making all make the grade quite easily. Note that the amount of documentation required is fairly minimal. Physicians often tend to OVERDOCUMENT this level of care.
History
The clinical example satisfies the requirements for an Expanded Problem Focused History. This level of history requires chief complaint, a brief HPI consisting of one to three HPI elements, plus a single ROS. No PFSH elements are required. In the example, only one HPI element is used: modifying factors (worse when laying flat). Review of the cardiovascular system satisfies the single ROS requirement. Many physicians are unaware that a ROS is required for some hospital progress notes. In fact, at least some ROS is required for both a level 2 progress note (99232) AND a level 3 progress note (99233).
Physical Exam
Using the 1997 E/M guidelines, the clinical example satisfies the requirements for an Expanded Problem Focused Exam, which requires a total of six bullets from any organ systems. The following seven bullets were utilized:
- General appearance
- Three vital signs
- Auscultation of lungs
- Auscultation of the heart with notation of abnormal sounds and murmurs
- Examination of the abdomen with notation of presence of masses or tenderness
- Assessment of lower extremities for edema and/or varicosities
- Palpation of the skin and subcutaneous tissue (temperature and turgor)
Medical Decision-Making
The cognitive labor required for the clinical example satisfies the requirements for Moderate Complexity Medical Decision-Making. Note that the intellectual energy required and the acuity of care remains routine.
Moderate Complexity Medical Decision-Making requires TWO out of THREE of the following :
Problem Points
In the clinical example , the problems addressed 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 = 4
The established problem of CHF, though not yet optimally controlled is improving so scores one point. The established problem of hypertension is worsening due to hypervolemia so that counts for two points. The Hypokalemia would seem to qualify as a “self-limited” problem so counts as one point. One could make the argument that the patients edema and pre-renal azotemia count as problems as well, but since four points are already present, the question is moot.
Data Points
The data points for the clinical example 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 ordering/reviewing labs.
Risk
A review of the table of risk shows that the clinical example has Moderate Risk written all over it due to the presenting problems of “one or more chronic illness, with mild exacerbation” OR “two or more stable chronic illnesses” OR for the management option of “prescription drug management.” . |
| 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, four problem points, one data point and Moderate Risk add up to Moderate Complexity Medical Decision-Making. |
E/M University Coding Tip : It is interesting to note that the 99232 is far and away the most popular E/M code used to bill for hospital progress notes. As noted above, this code is used for almost 60% of these encounters. This level of care requires medical decision-making of moderate complexity. One has to wonder why the outpatient equivalent, the 99214, is used only about 27% of the time. Since both the 99232 and the 99214 require the same cognitive labor (Moderate Complexity Medical Decision-Making), one would expect them to be used in roughly equal proportion, but this is not the case. The argument can be made that hospital patients are “sicker”, but it is hard to believe that this would explain the magnitude of the difference altogether. It seems that, for some reason, physicians would be comfortable using the 99232 to code for a ham sandwich in the hospital, but balk at the prospect of using the 99214 with similar regularity in the office.
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