| |
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.
|
For this type of encounter three out of three key components must satisfy the documentation requirements for any particular level of care. In the example, the History, Physical Exam and Medical Decision-Making all make the grade easily
History
The example qualifies as a Comprehensive History which requires 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 are met by the use of a total of six HPI elements: location (chest), duration (two hours), quality (crushing), severity (8/10), timing (constant) and associated signs and symptoms (shortness of breath and nausea). The PFSH elements used are self-explanatory and clinically relevant. Note that at least ONE element from EACH category of PFSH is present. The ROS requirements were fulfilled by commenting on pertinent findings and making use of the accepted ROS shorthand of “all others negative.”
Physical Exam
Using the 1997 E/M guidelines, the clinical example qualifies as a Comprehensive Physical Exam which requires two bullets in EACH of nine organ systems. All of the elements included must be probative and clinically informative in order to fulfill the requirement of medical necessity. 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)
- ophthalmoscopic discs and posterior segments
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
- examination of the carotid arteries (e.g., pulse amplitude, bruits)
- 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
Notice that 25 bullets in 11 systems are utilized, even though this is more than is needed for E/M compliance. This reflects the fact that a conscientious exam often includes more elements than required by the E/M guidelines.
Medical Decision-Making
The cognitive labor required for the clinical example satisfies the requirements for High Complexity Medical Decision-Making.
Moderate Complexity Medical Decision-Making requires TWO out of THREE of the following :
Problem Points
For the clinical example, the 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 = 7
In the example four problem points are garnered for chest pain which will obviously require further work-up. The patient’s hypertension is not controlled so this counts as two points. The diabetes is controlled and counts as one point. Therefore seven total points are scored. Note that even thought the major problem is chest pain (and concern for acute MI), the diabetes and hypertension should also be counted in the problem points because their presence significantly impacts the treatment and prognosis of the patient’s suspected coronary disease
Data Points
For the clinical example, the problems would be 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 = 6
Two data points EACH are scored for the physician personally reviewed the chest X-ray and EKG tracing and recorded the findings in the chart. One data point is scored for ordering an echocardiogram. One point is scored for reviewing/ordering lab tests. .
Risk
A review of the table of risk shows that the clinical example qualifies as being of High Risk due to the presenting problems of an “acute or chronic illness or injury, which poses a threat to life or bodily function.” |
| 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 severe exacerbation or progression
- Acute or chronic illness or injury, which poses a threat to life or bodily function, e.g., multiple trauma, acute MI, pulmonary embolism, severe respiratory distress, progressive severe rheumatoid arthritis, psychiatric illness, with potential threat to self or others, peritonitis, ARF
- An abrupt change in neurological status, e.g., seizure, TIA, weakness, sensory loss
|
- Cardiovascular imaging, with contrast, with identified risk factors
- Cardiac EP studies
- Diagnostic endoscopies, with identified risk factors
- Discography
|
- Elective major surgery (open, percutaneous, endoscopic), with identified risk factors
- Emergency major surgery (open, percutaneous, endoscopic)
- Parenteral controlled substances
- Drug therapy requiring intensive monitoring for toxicity
- Decision not to resuscitate, or to de-escalate care because of poor prognosis
|
|
| 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 |
|
| In this case, all three dimensions of Medical Decision-Making, (seven problem points, five data points and High Risk) add up to High Complexity Medical Decision-Making. |
E/M University Coding Tip : Notice that initial counters often require review of a significant amount of data. In settings like the ER, it is always best to personally review images and tracings and record your findings. Even if you interpret an image or tracing which has already been officially “read” by another clinician (such as a CXR which already has an official radiologist interpretation), you CAN still count these data points as long as you personally review the image or tracing and record your findings in the chart.
|
|
|
