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Problem Points

The “nature and number of clinical problems” are quantified into Problem Points by referring to the following table:


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
The above table is fairly self explanatory.  An example of a “self-limited or minor” problem may be a common cold or an insect bite.  An “established problem” refers to a diagnosis which is already known to the examiner, such as hypertension, osteoarthritis or diabetes.  An example of a “new problem with no additional work-up planned” may be a new diagnosis of essential hypertension.  Examples of “new problem, with additional work-up planned” may include any new clinical issue which requires further investigation such as chest pain, proteinuria, anemia, shortness of breath, etc

E/M University Coding Tip: Problems which are not being addressed specifically by the physician during the encounter may still be counted if they significantly increase the complexity of the cognitive labor required.  For example, consider a patient with diabetes who is being evaluated by a vascular surgeon for a lower extremity revascularization procedure.  It would be appropriate for the surgeon to include diabetes as an “established problem, stable” when calculating the problem points.  This is because the comorbidity of diabetes does significantly influence the risk of the procedure and the complexity of the post operative management.

E/M University Coding Tip: Problems are defined relative to the examiner, not the patient.  Even if the problem was previously known to other physicians or to the patient, it is still considered new to you if you are seeing the patient for the first time. This situation arises often in the case on consultations.
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