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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 example above, the History, Physical Exam and Medical Decision-Making all make the grade easily
History
The clinical example qualifies as a Problem Focused History which requires only a chief complaint and a brief HPI (one to three HPI elements). In this case three HPI elements were actually used: location (abdominal discomfort), severity (mild) and quality (colicky). 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 the abdomen with notation of presence of masses or tenderness
- Examination of the penis
Medical Decision-Making
The cognitive labor required for the clinical 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.
Straightforward Medical Decision-Making requires TWO out of THREE of the following:
Problem Points
For the clinical example , the problem points are scored as follows : |
Problems |
Points |
Example |
Self-limited or minor (maximum of 2) |
1 |
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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 = 1
In the example, the presence of one “self-limited or minor problem” of transient post-anesthesia urinary retention adds up to one problem point .
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 |
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Review or order
medicine test (PFTs, EKG, cardiac echo or cath) |
1 |
|
Discuss test
with performing physician |
1 |
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Independent
review of image, tracing, or specimen |
2 |
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Decision to
obtain old records |
1 |
|
Review and
summation of old records |
2 |
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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
Requires ONE of 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
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- 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
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 : Very little documentation or cognitive labor is required for this level of care .
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