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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, Physical Exam and Medical Decision-Making  all make the grade easily. 


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 (nasal), duration (five days) and associated signs and symptoms (cough).  Notice that no ROS or PFSH are required.

Physical Exam

Using the 1997 E/M guidelines, the clinical example DOES qualify as a Problem Focused Exam, which requires the documentation only 1 -5 bullets.  The following four bullets were utilized:
  • General appearance
  • Three vital signs
  • Examination of oropharynx
  • Auscultation of lungs
Medical Decision-Making

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

Moderate 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 = 1

In the example, the presence of one “self-limited or minor problem” of a common cold 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 . 


Review of the table of risk shows that this encounter qualifies as Minimal Risk due to the presenting problem a common cold which may be described as “one self-limited or minor problem.”
Risk Level Presenting Problems Diagnostic Procedures Management Options Selected
Minimal Risk

equires ONEof 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
  • 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 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 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 :The reason that all three key components qualify for this particular example is that the documentation requirements for this level of care are so minimal it’s hard NOT to qualify.  This example actually documented more than the minimum required.  The physician could just as easily have documented the history as “The patient thinks he has a cold” and the documentation requirements would have been met because of the qualifying exam and medical decision-making.   It’s hard to believe that a person would seek medical attention for this type of self-limited problem, but apparently it does happen.  Among all physicians in 2003, this level of care was charged for established office patients an astonishing 27,307,135 times .

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