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For this type of encounter only two out of three key components must satisfy the documentation requirements for any particular level of care.  In the example above, the History and Medical Decision-Making make the grade, while the Physical Exam falls well short.  Note that the amount of documentation required is fairly minimal.  Physicians often tend to OVERDOCUMENT the 99213.


The clinical example satisfies the requirements for an Expanded Problem Focused History.  This level of history requires a 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, only two HPI elements are used: location (left knee) and duration (two weeks).  Review of the musculoskeletal system satisfies the single ROS requirement.

Physical Exam

Using the 1997 E/M guidelines, the clinical example does NOT qualify as an Expanded Problem Focused Exam.  This level of exam would require documentation of at least of six bullets from any organ systems.   The documentation is still compliant with the E/M guidelines for this level of care because this type of encounter requires complete documentation of only two out of three qualifying key components.  (In this case the History and Medical Decision-Making both qualify).  The physical exam in the example qualifies only as a Problem Focused Exam because it utilizes just the following three bullets:
  • General appearance inspection and/or palpation with notation of presence of any misalignment, asymmetry, crepitation, defects, tenderness, masses or effusions
  • Assessment of range of motion with notation of any pain, crepitation or contracture
  • Inspection of skin and subcutaneous tissue (e.g., rashes, lesions, ulcers)
Medical Decision-Making

The cognitive labor required for the clinical example satisfies the requirements for Low Complexity Medical Decision-Making.  Note that the intellectual energy required and the acuity of care are both minimal:

Low 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 = 2

The presence of the one “established problem, worsening” of osteoarthritis adds up to two 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 = 0

No data points are scored for this encounter because no eligible data was reviewed.


Review of the table of risk shows that this encounter qualifies as Low Risk due to the management  option of  “over-the-counter drugs.”
Risk Level Presenting Problems Diagnostic Procedures Management Options Selected
Minimal Risk

equires ONEof these elements in ANY of the three categories listed

  • Two or more self-limited or minor problems
  • One stable chronic illness, e.g., well controlled HTN, DM2, cataract
  • Acute uncomplicated injury or illness, e.g., cystitis, allergic rhinitis, sprain
  • Physiologic tests not under stress, e.g., PFTs
  • Non-cardiovascular imaging studies with contrast, e.g., barium enema
  • Superficial needle biopsy
  • ABG
  • Skin biopsies
  • Over the counter drugs
  • Minor surgery, with no identified risk factors
  • Physical therapy
  • Occupational therapy
  • IV fluids, without additives
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, two problem points, no data points and Low Risk add up to Low Complexity Medical Decision-Making
E/M University Coding Tip : What is truly striking about the acuity of care required for a 99213 visit is its benignity.  It is difficult to believe that over fifty percent of established office patients in the Medicare population fall into this innocuous category.  It is more likely that the 99213 is grossly OVER-USED.  Many physicians may choose this level of care because it is located “in the middle” and seems like the right code to use for “routine” visits.    However, if you take the time to calculate the MDM for many of these “routine”  encounters you will find that the cognitive labor required rises above the level of the 99213 and cross the threshold to the 99214.  The fact that the 99213 is used so often may reflect a pattern of chronic undercoding by almost all physicians.  If you take the time to systematically evaluate your MDM using the point system, you can avoid this trap .

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