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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
The clinical example qualifies as a Comprehensive History which requires a chief complaint, an extended HPI consisting of four HPI elements (or the status of three chronic or inactive problems—if using the 1997 guidelines only), a complete ROS (which requires at least 10 systems), and a complete PFSH (which in this case requires at least ONE element from each PFSH category). In the above example, the requirements for the HPI were met by commenting on the status of three chronic or inactive problems (hypertension, diabetes, coronary artery disease). The PFSH elements used are self-explanatory. Note that it ONLY TAKES ONE element from EACH category of PFSH to qualify for a complete PFSH. The ROS requirements were fulfilled by using a form for a complete ROS filled out by the patient prior to seeing the physician. Notice that the date and location of the ROS form as well as pertinent findings are clearly recorded in the chart.
Physical Exam
Using the 1997 E/M guidelines, this example qualifies as a Comprehensive Physical Exam which requires two bullets in EACH of nine organ systems. The following bullets and systems were used:
Constitutional
- 3 vital signs
- general appearance
Eyes
- inspection of conjunctiva and lids
- examination of pupils and irises (PERRLA)
Ears, Nose, Mouth, and Throat
- external appearance of the ears and nose (NC/AT)
- examination of oropharynx:
Neck
- examination of neck (e.g., masses, symmetry, tracheal position)
- examination of thyroid
Respiratory
- assessment of respiratory effort (e.g., intercostal retractions)
- auscultation of the lungs
Cardiovascular
- auscultation of the heart with notation of abnormal sounds and murmurs
- assessment of lower extremities for edema and/or varicosities
Gastrointestinal (Abdomen)
- examination of the abdomen with notation of presence of masses or tenderness
- examination of the liver and spleen
Lymphatic (palpation of lymph nodes two or more areas)
Skin
- inspection of skin and subcutaneous tissue (e.g., rashes, lesions, ulcers)
- palpation of the skin and subcutaneous tissue (temperature and turgor)
Psychiatric
- orientation to time, place, and person
- mood and affect
A total of 10 systems with two bullets each were included, even though the requirement is only for nine systems with two bullets each.
Medical Decision-Making
The cognitive labor required for the above example satisfies the requirements for Moderate Complexity Medical Decision-Making. Note that the intellectual energy required and the acuity of care remain fairly routine.
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 |
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| Established problem, worsening |
2 |
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| New problem, with no additional work-up planned (maximum of 1) |
3 |
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| New problem, with additional work-up planned |
4 |
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Total Problem Points = 4
The four established and stable problems of hypertension, diabetes, dyslipidemia, and CAD are added up individually for a total of four problem points. This example illustrates the fact that it is not necessary for the physician to “do something” about each diagnosis in order to claim the problem points. Sometimes “doing nothing” is the right thing to do. This does not subtract from the complexity of managing patients with multiple interlocking diagnoses.
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 |
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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 |
Moderate Risk
Requires any 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
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- 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
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- 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 |
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| 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 : (This tip is the corollary to the E/M University Coding Tip following the 99203.) Although the 99204 is the second most popular code used to bill for new office patients, this level of care remains grossly under-utilized by most physicians. This assertion is based on the fact that the Moderate MDM required for this encounter is often misunderstood. If you examine the rules for calculating the MDM you will find that it doesn’t take much to qualify for Moderate Complexity MDM. In fact, looked at from a strictly objective standpoint (using the MDM points system) it becomes apparent that the cognitive labor required for the 99204 code is more congruent with a “routine” clinical visit than the Low Complexity MDM required for the 99203 code. But for some reason, physicians over-utilize the 99203 code at the expense of the higher paying 99204 code. Calculating the MDM points prior to finalizing your code selection can help you avoid this trap and ensure appropriate reimbursement.
This topic is covered in more detail in our web-based E/M coding courses. |
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New Office Patients |
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