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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), 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, six HPI elements were utilized: location (chest), duration (two to three weeks), timing (intermittent), quality (squeezing), modifying factors (worse with exertion, improved with rest) and associated signs and symptoms (shortness of breath and diaphoresis). 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. 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
A total of 10 systems with at least 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 clinical example satisfies the requirements for High Complexity Medical Decision-Making. Note that the patient is not critically ill, but has multiple chronic and progressive medical problems. In addition, a significant amount of data was addressed by the physician.
Moderate Complexity Medical Decision-Making requires TWO out of THREE of the following :
Problem Points
In the clinical example, 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 |
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| New problem, with no additional work-up planned (maximum of 1) |
3 |
|
| New problem, with additional work-up planned |
4 |
|
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Total Problem Points = 7
Four points are scored for the new problem of possible unstable angina which requires additional work-up. Two points are scored for the established, but not controlled problem of hypertension. One point is scored for the established and stable problem of diabetes.
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 = 5
Two data points are scored because the physician personally reviewed the EKG tracing and recorded the findings in the chart. Review of the X-ray report and lab work count as one point each. Finally one point is garnered for ordering the echocardiogram.
Risk
A review of the table of risk shows that this encounter qualifies as being of High Risk due to the presenting problem of unstable angina which would qualify as an “acute or chronic illness…posing a threat to life of 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
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- Cardiovascular imaging, with contrast, with identified risk factors
- Cardiac EP studies
- Diagnostic endoscopies, with identified risk factors
- Discography
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- 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
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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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| In this case all three factors of seven problem points, five data points and High Risk add up to High Complexity Medical Decision-Making. |
E/M University Coding Tip : In this example, High Risk is obvious but physicians should remember that this level of medical jeopardy is not absolutely necessary to qualify for High Complexity Medical Decision-Making. 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.
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