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99252 E/M INSIGHT
 

 

 


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 clinical example, the History, Physical Exam and Medical Decision-Making  all make the grade easily

History

This example qualifies as an Expanded Problem Focused History which requires chief complaint, a brief HPI consisting of one to three HPI elements, plus a single ROS.  No PFSH elements are required.  In the above example, four HPI elements are used: context (rash developed following cephalosporin exposure), location (all over), duration (since yesterday) and associated signs and symptoms (generalized itching).  Review of the integumentary system satisfies the single ROS requirement..

Physical Exam

Using the 1997 E/M guidelines, the 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
  • Assessment of lower extremities for edema and/or varicosities
  • Inspection of skin and subcutaneous tissue
  • Palpation of the skin and subcutaneous tissue
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
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 = 1

In the example, the presence of one “self-limited or minor problem” of a drug rash 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  
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 = 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 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
  • Rest
  • Gargles
  • Elastic bandages
  • Superficial dressings
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
In this case, all three components of Medical Decision-Making 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 : It’s interesting to note that the 99252 code requires the exact same level of Medical Decision-Making as the lower paying 99251 code.  In this case, the reimbursement is exactly double for the 99252 code even though the physician is performing the same cognitive labor used for the 99251 visit (as reflected by the Medical Decision-Making).  The only rational reason to use the 99251 code instead of the 99252 would be when the clinical circumstances of the encounter do not support the slightly more detailed history (in this case the addition of one ROS) and the slightly more intensive physical exam (six bullets as opposed to one to five bullets) which is required for the 99252 .

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