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 only two out of three key components must satisfy the documentation requirements for any particular level of care. In the clinical example, the History and Medical Decision-Making make the grade, while the Physical Exam falls well short, but that's okay because we don't need all three components to qualify. This example illustrates the fact that medical necessity should guide the physician in terms of the documentation of the key components. In the above clinical scenario it would be difficult to justify performing a Comprehensive Exam. On the other hand, it is certainly reasonable and medically necessary to perform a Comprehensive History to identify other possible causes for the constellation of clinical symptoms (e.g., PMH of renal insufficiency, renal artery stenosis, diastolic CHF, nephrotic syndrome, etc)
History
The
clinicalexample satisfies the requirements for a
Comprehensive History.
This level of history
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. In this case, since it is a follow-up office visit with an established patient a complete PFSH requires at least
ONE element from only
two out
three PFSH categories (as opposed to three out of three PFSH components if this were a consult or new patient).
In the example, the requirements for the HPIare met by commenting on the status of three chronic or inactive problems (cardiomyopathy, hypertension, and coronary artery disease).
The PFSH requirements were fulfilled by using a legal
PFSH shortcut of referring to a previously dictated note already located in the chart.
Note that the date and location of the relevant information is stated clearly in the record.
The
ROS requirements were fulfilled by
using a form for a complete
ROS filled out by the patient prior to seeing the physician.
Notice that the date and location of the
ROS form as well as pertinent findings are clearly recorded in the chart.
Physical Exam Using the 1997 E/M guidelines, the above example does NOT qualify as a
Comprehensive Exam.
This level of exam would require documentation of at least of two
bullets from EACH of nine
organ systems.
The documentation is still compliant with the E/M guidelines for this level of care because this type of encounter requires 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 an
Expanded Problem Focused Exam because it utilizes just the following eight bullets:
· General appearance
· Three vital signs
· Auscultation of the heart with notation of abnormal sounds and murmurs
· Auscultation of lungs
· Examination of the abdomen with notation of presence of masses or tenderness
· Examination of the liver and spleen
· Assessment of lower extremities for edema and/or varicositie
· Inspection and/or palpation of digits and nails
Medical Decision-Making The cognitive labor required for the above example satisfies the requirements for
High Complexity Medical Decision-Making.
Note that the patient is not critically ill and does not require admission to the hospital, but has multiple chronic medical problems which are not controlled.
High Complexity Medical Decision-Making requires
TWO out of
THREE of the following:
- Four Problem Points
- Four Data Points
- High Risk
Problem Points For the above 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 = 5 Two points are scored for the established, but not controlled problem of ischemic cardiomyopathy. Two points are scored for the established, but not controlled problem of hypertension. One point is scored for stable CAD. This adds up to a total of five problem points for the above encounter. You could also consider adding three points for the “new” problem of pulmonary edema or lower extremity edema, but since the maximum possible problem points needed are four, why bother? Data Points The data points for the above example 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 = 1 Only one data point is garnered for this encounter for reviewing/ordering labs. Risk A review of the
table of risk shows that this encounter qualifies as being of
High Risk due to the presenting problems of “one or more chronic illness with severe exacerbation or progression.”
Risk Level | Presenting Problems | Diagnostic Procedures | Management Options Selected |
| High Risk Requires ONE of 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
| - Cardiovascular imaging, with contrast, with identified risk factors
- Cardiac EP studies
- Diagnostic endoscopies, with identified risk factors
- Discography
| - 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
|
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, four problem points, one data point and High Risk add up to High Complexity Medical Decision-Making. E/M University Coding Tip: The 99215 is the big kahuna—the great white whale of E/M coding.
All doctors secretly want to use this code more often, but few actually do.
This example illustrates the fact that a patient does not have to be “at death’s door” to qualify for the
99215 level of care.
A careful and objective calculation of the Medical Decision-Making is the first step to recognizing these patients in daily practice.
The judicious use of some of the legal documentation
shortcuts (e.g., for the PFSH and
ROS ) can ensure that the volume of information required is not prohibitive. The key is to document smartly—not excessively. 
