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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 qualify for this level of care.


This Comprehensive History 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), 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 using the following HPI elements: duration (two weeks), context (at rest or with exertion), timing (intermittent), modifying factors (worse when laying flat) and associated signs and symptoms (associated with lower extremity swelling). Note that a total of five HPI elements were used even though only four are technically required.   The PFSH elements used are self-explanatory.  Note that at least ONE element from EACH category of PFSH is present.  The ROS requirements were fulfilled by listing a few individual systems and then stating that “all other systems were reviewed and are negative”, which is certainly acceptable according to the E/M guidelines.

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:


  • 3 vital signs
  • general appearance


  • 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:


  • examination of neck (e.g., masses, symmetry, tracheal position)
  • examination of thyroid


  • assessment of respiratory effort (e.g., intercostal retractions)
  • auscultation of the lungs


  • 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)

  • neck
  • other (extremities)


  • inspection of skin and subcutaneous tissue (e.g., rashes, lesions, ulcers)
  • palpation of the skin and subcutaneous tissue (temperature and turgor) 


  • 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 High Complexity Medical Decision-Making.  Note that the patient is not critically ill, but has multiple chronic medical problems which are not controlled.  In addition, a significant amount of data was processed by the physician.

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 = 4

Three points are scored for the "new" problems of HTN, diabetes, dyslipidemia, CAD for which no further workup is planned (max of one problem for this category). Four points are given for the "new" problem of CHF because further workup is ordered. This adds up to a total of seven 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 = 4

Four total data point are scored for reviewing and/or ordering lab tests (1 point), ordering the CXR (1 point), ordering an echo (1 point) and making the decision to obtain records from another source (1 point).


A review of the table of risk shows that this encounter qualifies as being of Moderate Risk due to the presenting problems of “one or more chronic illness with mild exacerbation or progression.”  It also qualifies for this level of risk based on the management options selected of “prescription drug management”. 
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
  • 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
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, four data points and Moderate Risk add up to High Complexity Medical Decision-Making.

E/M University Coding Tip : Often the patient does not have to be in medical extremis to justify billing the highest level of care.  Even in cases where High Risk is not present, the MDM may still qualify as High Complexity on the basis of the problem points and data points.  (Remember, it only takes two out of three elements of MDM to qualify for any given level of complexity.)  This situation comes up most frequently during “new” encounters (consults, H&Ps, and new office patients) when the data points often represent the “low hanging fruit” of the MDM process.  Physicians often fail to give themselves credit for their cognitive labor by neglecting to factor in the data points when calculating the MDM.  This can lead to systematic undercoding.

This topic is covered in more detail in of one of our web-based E/M coding courses.

New Office Patients

New Office Patients
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