Selecting an E/M level focuses upon the content of the three key components: history, physical examination (PE), and medical decision making (MDM). Time is considered a fourth key component, but only affects the E/M level when counseling and/or coordination of care dominate more than 50% of the physician's total visit time (see below). When counseling and/or coordination of care involves less than 50% of the physician's total visit time, both time and the nature of the presenting problem are only considered as contributory factors and do not determine the E/M level.
Two sets of documentation guidelines have been elaborated by Medicare and largely adopted by other payers. The earlier 1995 guidelines are the most widespread, and generally applicable to hospitalists along with most medical and surgical specialists. The later 1997 guidelines elaborate specialty-specific physical examinations, as well as clearly articulate detailed physical examination requirements lacking in the 1995 guidelines. Several nuanced differences also exist between the two guidelines in aspects of history. The 1995 guidelines will be described in detail throughout this section, and the 1997 guidelines are highlighted below in a separate section for completeness.
The elements of history include the chief complaint (CC), history of present illness (HPI), review of systems (ROS), and the past, family, and social histories (PFSH). A chart note may not segregate these elements into unique subtitled areas, but rather the information may be interspersed amid the written, typed, or even dictated narrative.
Typically, the reason for the visit is often quoted from the patient's own words as a sign or symptom, such as, “my belly hurts.” Always document a CC in the progress note, even absent an acute complaint, such as, “pneumonia follow-up.” Avoid statements lacking a specific clinical reference (eg, “postop visit Day#3”).
History of Present Illness (HPI)
The HPI conveys information about the CC, from either the origin (at an initial encounter) or the interval between sequential patient encounters. This information is arbitrarily allocated into eight elements: location, quality, severity, duration, timing, context, modifying factors, and associated signs/symptoms. The HPI is then quantified as brief (one to three elements) or extended (four or more elements). For example, consider this extended HPI: “Patient complains of increased (severity) pedal (location) edema that began two days ago (duration). Less able to walk. No chest pain (associated signs/symptoms).”
The ROS refers to signs or symptoms experienced in conjunction with the CC. Fourteen systems are recognized: constitutional, eyes, ears/nose/mouth/throat, cardiovascular, respiratory, gastrointestinal, genitourinary, musculoskeletal, integumentary (which includes the breast), neurologic, psychiatric, endocrine, hematologic/lymphatic, and allergic/immunologic. Medical necessity, as deemed by the treating provider in light of the patient's current or previous conditions, determines the number of systems required for review.
An ROS may be problem pertinent, extended, or complete. A problem-pertinent ROS documents one system directly related to the CC. An extended ROS requires documentation of two to nine systems, that is, the system that is directly related to the CC, along with one or more additional systems. A complete ROS documents 10 or more individual systems. When obtaining a complete ROS, to decrease the amount of time spent listing each system individually, both the 1995 and 1997 (see below) E/M documentation guidelines allow the physician to comment on the positive and pertinent negative systems, with an additional comment that the “remainder is negative.” However, insurers may not accept alternative phrases, and even some Medicare contractors (eg, Trailblazers Medicare) require individual documentation of each system.
Past, Family, and Social Histories (PFSH)
The past history includes documentation of previous illnesses, hospitalizations, surgeries, medications, allergies, and immunizations. The family history provides information regarding potential hereditary illnesses. The social history may list details of the patient's substance use (tobacco/alcohol/illicit drugs), sexual history, employment status, level of education, marital status, or living arrangements.
A pertinent PFSH includes a comment in any one of the three histories (ie, past, family, or social). Full credit for a complete PFSH requires a comment in each history (ie, past, family, and social). When reporting initial hospital, observation, or nursing facility care, consultations, and new office, home, and domiciliary visits, a complete PFSH comprises one comment documented in each of the three histories. In contradistinction, emergency department (ED) services or established patient visits in the home, domiciliary, office, or other outpatient area require one comment in two of the three histories for credit as a complete PFSH.
Providers may review and comment that the “family history is noncontributory” and still receive credit for the family history from most insurers. Certain Medicare contractors, such as Trailblazers Medicare and Wisconsin Physicians Service Insurance Corporation, prohibit this terminology and require specific documentation regardless of clinical relevance (eg, “family history negative for liver disease”). Also note that with subsequent services, both for hospital care and nursing facility visits, indicating an “interval history” does not require redocumentation of the PFSH unless it is clinically relevant.
Determination of History Level
The number of historical elements present in the chart note determines the level of history (Table 28-1). If all of the requirements are not met for a given level of history, select the level associated with the deficient element. For example, a comprehensive history requires documentation of the CC, ≥4 HPI elements, ≥10 ROS, and a complete PFSH. If the ROS only includes documentation for 9 systems, a comprehensive history cannot be selected; report a service that requires only a detailed history: CC, ≥4 HPI elements, 2-9 ROS, and a pertinent PFSH.
Table 28-1 Levels of History ||Download (.pdf)
Table 28-1 Levels of History
|Expanded problem-focused||Brief (≤3)||Problem pertinent (1)||None|
|Detailed||Extended (≥4)||Extended (2–9)||Pertinent (1)|
|Comprehensive||Extended (≥4)||Complete (≥10)||Complete (2 or 3)ch28fn01|
A PFSH obtained during an earlier encounter does not need to be rerecorded if the provider demonstrates review and updating of the previous information. Update the history by describing any new information or noting the absence of change, along with the date and location of the earlier PFSH; this earlier PFSH must be contained in the body of the medical record. CPT requires only an interval history for subsequent hospital or subsequent nursing facility visits, and it is usually unnecessary to record information about the PFSH, which is unlikely to change in these settings. For established outpatient encounters, documentation regarding the PFSH is unnecessary when PE and MDM are used as the basis for the level of the encounter, unless the patient provides the physician with updated information.
Most auditors disallow a single statement as both an HPI element and ROS element. The ROS and/or PFSH may be recorded by ancillary staff, or on a form completed by the patient. The provider must annotate, supplement, or confirm this information recorded by others, either by a reference to the history form in the progress note or by initialing and dating the form.
If unable to obtain history from the patient, the record should describe the patient's condition or the circumstance that precludes obtaining a history. For example, ″… patient sedated and paralyzed, unable to obtain additional history.″ However, reviewers expect providers to incorporate historic information to the extent possible, from all reasonably available sources (eg, old records, Emergency Medical services documents, other provider documentation, or conversations).
Finally, although the physician may collect all of the information required for a complete ROS, the most common under-documentation error is failure to document at least 10 systems. The second most common mistake is a missing family history or social history.
- Although the physician may collect all of the information required for a complete review of systems, the most common underdocumentation error is failure to document at least 10 systems. The second most common mistake is a missing family or social history.
Physical Examination (PE)
Individual PE elements will be assigned to body areas (head and face, neck, chest, abdomen, genitalia/groin/buttocks, back/spine, and each extremity) or organ systems (constitutional, eyes, ears/nose/mouth/throat, cardiovascular, respiratory, gastrointestinal, genitourinary, musculoskeletal, integumentary, neurologic, psychiatric, and hematologic/lymphatic/immunologic). Providers may document specific findings (eg, “abdomen soft”) or make a generalized comment (eg, “HEENT normal”). Abnormal findings must be specifically documented, such as “S3”; however, a comment indicating “abnormal” without elaboration is insufficient.
The PE documented in the medical record is categorized as problem-focused, expanded problem-focused, detailed, or comprehensive. One comment in an area constitutes a problem-focused exam. The distinction between the expanded problem-focused and detailed examination under the 1995 Guidelines is the greatest ambiguity in physical examination documentation. Both the expanded problem-focused and detailed exams require documentation of two to seven systems. However, “detailed” is defined as an extended examination of the affected body area or organ system, in addition to other symptomatic or related organ systems. The number of required comments regarding the affected body area or organ system to consider the examination detailed has never been defined by either CPT or Medicare. Attempting to decrease ambiguity and variability among auditors, Highmark Medicare Services scores a detailed exam using the “4 × 4” rule: 4 elements examined in 4 body areas or 4 organ systems (totaling 16 documentation elements). In contrast, Trailblazers Medicare and some other contractors suggest using the 1997 guidelines (discussed later) for detailed exam requirements.
The comprehensive examination is a general multisystem examination or a complete examination of a single organ system. Medicare requires the minimum documentation for the general multisystem examination to include one comment in each of eight systems; of course, additional comments in each system and more than eight systems may be described, as clinically indicated. For example, a comprehensive examination may be documented as follows: “P=76, BP=120/80, RR=12 (constitutional); HEENT normal (eyes and ENMT); neck supple (musculoskeletal); regular rate and rhythm (cardiovascular); lungs clear (respiratory); soft abdomen (gastrointestinal); no icterus (integumentary), normal gait (neurological).” The requirements for a comprehensive single organ system still remain undefined for use with these 1995 guidelines.
Medical Decision Making (MDM)
The complexity of MDM drives selection of a level of service. MDM is categorized as straightforward, low, moderate, or high. Three categories must be considered to determine the level of MDM complexity: the number of diagnoses, the amount and complexity of data, and the risk to the patient.
Number of Diagnoses Considered
This first category identifies the number of diagnoses and/or management options considered in the encounter, based upon the documentation. Up to four points are assigned to each problem, with more points assigned for new problems than for established problems, and a new problem requiring additional workup (ie, diagnostic testing) given the maximum four points. Established problems identified as worsening receive a higher value than stable or improving problems. A self-limited or minor problem (eg, sunburn) receives minimal credit as these issues typically do not warrant a defined plan of care (Table 28-2).
Table 28-2 Valuation of Diagnostic and Treatment Options ||Download (.pdf)
Table 28-2 Valuation of Diagnostic and Treatment Options
|Number of Diagnoses/Treatment Options||Points per Problem|
|Self-limited/minor problem (stable, improved, or worsening)||1 (max = 2 problems)|
|Established problem (stable or improving)||1|
|Established problem (worsening)||2|
|New problem, without additional workup||3 (max = 1 problem)|
|New problem, with additional workup planned||4|
New problems require initiation of a care plan, while established problems may require modification or continuation of a care plan. An established problem has been previously considered by the physician or provider group (to allow for cross coverage and handoffs between same specialty providers in the same group). Note that credit is given for a problem considered, although not primarily under treatment by the physician. For example, in a patient receiving steroids for an inflammatory disease, the hospitalist receives credit for noting the potential adverse consequence upon serum lipids, even if a cardiologist is primarily treating the dyslipidemia. Similarly, a chronic condition such as diabetes, cared for by an endocrinologist, is categorized as a new problem to the hospitalist newly treating the patient during an admission for ketoacidosis.
Established patients may also have new problems. For example, an asthmatic with a resolving flare may experience heartburn. This additional new complaint of heartburn may be considered new if commented upon in the progress note and no prior care plan for gastroesophageal reflux exists.
Physicians receive credit only for issues considered in the care plan. Diagnoses merely listed in the assessment and plan without elaboration of the care, or simply ascribing the care to others (eg, “diabetes – per endocrinologist”) are considered part of the patient's problem list in the PFSH. Additionally, new hospitalizations warrant new care plan development, and physicians can receive new problem credit even if the patient has been previously hospitalized by the same group. This is a nuance of inpatient and observation care only.
The second category of determining the MDM complexity is the amount and/or complexity of data reviewed or ordered by the provider during the patient encounter. Both the type and source of information considered are valued (Table 28-3).
Table 28-3 Valuation of Data Considered ||Download (.pdf)
Table 28-3 Valuation of Data Considered
|Amount and/or Complexity of Data Ordered/Reviewed||Points|
|Review and/or order of clinical test(s)||1|
|Review and/or order of test(s) in the pathology/laboratory section of CPT||1|
|Review and/or order of test(s) in the radiology section of CPT||1|
|Review and/or order of test(s) in the medicine section of CPT||1|
|Decision to obtain old records and/or obtain history from someone (nonhealth care provider) other than the patient||1|
|Review and summarize old records, obtain additional history, or discuss the case with another health care provider||2|
|Independent visualization of actual image, tracing, or specimen||2|
Ordering and/or reviewing of pathology/laboratory, radiology, and medicine data each provide separate but equal credit. Irrespective of the test volume in each category, only one point is allocated per category (ie, pathology/laboratory, radiology, or medicine) for the encounter. For example, the provider ordering a dozen serologic collagen vascular studies in the morning may also review the three results received in the afternoon; nonetheless, only one point is granted for this care. A single, separate point may be assigned each to pathology/laboratory, radiology, and medicine data, respectively, are cumulative in nature, and the chart note should refer to all the data reviewed or ordered to capture all of the provider work. In other words, if the chart note comments upon a radiology result (one point) and an echocardiogram order (one point), two points may be awarded for the amount of data in that encounter. Independently visualizing images, tracings, or specimens is considered separately, and additional to reviewing the formal interpretation, as long as the chart note clearly documents this occurrence (ie, ″…films and report reveal…″). Without such specific reference distinguishing personal review of the images and of the formal interpretation, an auditor only provides minimal credit for merely reviewing the report.
Providers also receive credit for the additional effort of obtaining information from sources other than the patient or old records, such as conversations with other health care professionals. The chart note should specifically mention the source, along with the information reviewed (eg, ″…spouse confirms loud snoring″).
The third MDM category assesses the patient's risk of complications, morbidity, or mortality, with respect to the presenting problem, diagnostic procedures ordered, or management options chosen. Four levels of patient risk exist (minimal, low, moderate, and high), with examples of each risk type included in Medicare's “Table of Risk” (Table 28-4). The limited number of examples serves as illustrative references for common clinical scenarios, but not as a comprehensive list.
Table 28-4 Table of Risk ||Download (.pdf)
Table 28-4 Table of Risk
|Level of Risk||Presenting Problem(s)||Diagnostic Procedure(s) Ordered||Management Options Selected|
- One self-limited or minor problem (eg, cold, insect bite, tinea corporis)
- Laboratory tests requiring venipuncture
- Chest X-rays
- Ultrasound (eg, echocardiography)
- KOH prep
- Elastic bandages
- Superficial dressings
- Two or more self-limited or minor problems
- One stable chronic illness (eg, well-controlled hypertension, noninsulin dependent diabetes, cataract, BPH)
- Acute uncomplicated illness or injury, (eg, cystitis, allergic rhinitis, simple sprain)
- Physiologic tests not under stress (eg, pulmonary function tests)
- Noncardiovascular imaging studies with contrast (eg, barium enema)
- Superficial needle biopsies
- Clinical laboratory tests requiring arterial puncture
- Skin biopsies
- Over-the-counter drugs
- Minor surgery with no identified risk factors
- Physical therapy
- Occupational therapy
- IV fluids without additives
- One or more chronic illnesses with mild exacerbation, progression, or side effects of treatment
- Two or more stable chronic illnesses
- Undiagnosed new problem with uncertain prognosis (eg, lump in breast)
- Acute illness with systemic symptoms (eg, pyelonephritis, pneumonitis, colitis)
- Acute complicated injury (eg, head injury with brief loss of consciousness)
- Physiologic tests under stress (eg, cardiac stress test, fetal contraction stress test)
- Diagnostic endoscopies with no identified risk factors
- Deep needle or incisional biopsy
- Cardiovascular imaging studies with contrast and no identified risk factors (eg, arteriogram, cardiac catheterization)
- Obtain fluid from body cavity (eg, lumbar puncture, thoracentesis, culdocentesis)
- Minor surgery with identified risk factors
- Elective major surgery (open, percutaneous, or endoscopic) with no identified risk factors
- Prescription drug management
- Therapeutic nuclear medicine
- IV fluids with additives
- Closed treatment of fracture or dislocation without manipulation
- One or more chronic illnesses with severe exacerbation, progression, or side effects of treatment
- Acute or chronic illnesses or injuries that pose a threat to life or bodily function (eg, multiple trauma, acute MI, pulmonary embolus, severe respiratory distress, progressive severe rheumatoid arthritis, psychiatric illness with potential threat to self or others, peritonitis, acute renal failure)
- An abrupt change in neurologic status (eg, seizure, TIA, weakness, sensory loss)
- Cardiovascular imaging studies with contrast with identified risk factors
- Cardiac electrophysiological tests
- Diagnostic endoscopies with identified risk factors
- Elective major surgery (open, percutaneous, or endoscopic) with identified risk factors
- Emergency major surgery (open, percutaneous, or endoscopic)
- Parenteral controlled substances
- Drug therapy requiring intensive monitoring for toxicity
- Decision not to resuscitate or to de-escalate care because of poor prognosis
When determining the level of risk, consider comorbidities as well as the plan of care in assessing a patient's risk, thereby potentially increasing the complexity of MDM. Similarly, diagnostic studies or alternatively, procedures under consideration or excluded based upon excessive risk, impact the complexity of MDM (eg, ″…will defer MRI, as potential morbidity of transport to magnet exceeds risks of empiric treatment″). Although many bulleted items on the table may pertain to a particular chart note, the single bulleted item in any risk category associated with the highest risk determines the patient's risk level. For example, a note documenting the monitoring of liver function tests to assess for statin toxicity comprises high risk (drug therapy requiring frequent monitoring for toxicity). However, remember risk does not equal complexity: risk is but one category (among three) of MDM and not the sole contributor to complexity.
Based upon the chart note, points are assigned for diagnoses managed and data considered, and patient risk is assessed. The final result of MDM complexity hinges on the two highest-valued categories. In other words, two of the three categories must meet or exceed the requirements assigned to a specific level of complexity to select that level, as illustrated in Table 28-5.
Table 28-5 Levels of Medical Decision Making ||Download (.pdf)
Table 28-5 Levels of Medical Decision Making
|Complexity||Diagnosis or Treatment Option Points||Data Points||Risk Level|
|Problem-focused||≤1 (minimal)||≤1 (minimal)||Minimal|
|Low||2 (limited)||2 (limited)||Low|
|Moderate||3 (multiple)||3 (multiple)||Moderate|
|High||4 (extensive)||4 (extensive)||High|
To illustrate the assignment of MDM complexity, consider the following example. The chart note considers three stable established diagnoses (three points), several blood tests (one point), and high patient risk. The lowest of the three categories (data considered) is eliminated, and the lower of the two remaining categories (number of diagnoses) determines the moderate MDM complexity for the note. While most contractors utilize the same standardization when assigning points, beware of contractors (eg, Trailblazers Medicare) who impose different standards.
Medicare issued a second set of revised documentation guidelines for E/M services in 1997. MDM and the level categories remained unchanged from the prior 1995 documentation guidelines, as detailed above. While ambiguity plagues many aspects of the 1995 guidelines, excessive proscription limits the 1997 guidelines. The 1997 guidelines made a single minor revision to the history, while the physical examination content received extensive modification. The requirements for each level of physical examination were heavily revised, and specialty-specific single organ system examinations defined. In response to widespread complaints from the physician community, CMS allowed physicians to document using either the 1995 or 1997 guidelines, according to their individual preference, and directed auditors to review the physician documentation based on the set of guidelines most favorable to the physician for the E/M code reported for the encounter. Most physicians, including hospitalists, find the 1995 guidelines most applicable.
The 1997 guidelines do not limit the provider to identifying individual factors associated with the CC (eg, duration, timing, context). Rather, a provider may document the status of one or more chronic conditions; this option is most useful to subsequent hospital visits. A brief HPI documents one or two conditions, while an extended HPI documents a minimum of three conditions. Some reviewers allow this option only if applying the 1997 guidelines to the entire note.
The 1997 guidelines allow a provider to select either a general multisystem examination or any one of the single organ system examinations. Hospitalists typically utilize the general examination, which specifies examination elements to perform and document. Negative or normal comments remain acceptable for the 1997 guidelines, along with the mandate to specify comments on any abnormal findings. Documentation in the medical record of 1 to 5 specified (referred to as bulleted) physical examination elements comprises a problem-focused examination; 6 to 11 bulleted elements defines the expanded problem-focused examination; and a detailed examination requires 12 or more bulleted items.
Two important, major differences distinguish the 1997 comprehensive examination (Tables 28-6 and 28-7) requirement from the 1995 guideline. First, for the 1997 general multisystem exam, the provider must perform all the elements specified in at least nine organ systems or body areas. Second, the provider needs to document only a minimum of two elements from each of those nine systems or areas.
Table 28-6 1997 General Multisystem Physical Examination ||Download (.pdf)
Table 28-6 1997 General Multisystem Physical Examination
|System/Body Area||Elements of Examination|
- Measurement of any three of the following seven vital signs: (1) sitting or standing blood pressure, (2) supine blood pressure, (3) pulse rate and regularity, (4) respiration, (5) temperature, (6) height, (7) weight (may be measured and recorded by ancillary staff)
- General appearance of patient (eg, development, nutrition, body habitus, deformities, attention to grooming)
- Inspection of conjunctivae and lids
- Examination of pupils and irises (eg, reaction to light and accommodation, size, and symmetry)
- Ophthalmoscopic examination of optic discs (eg, size, C/D ratio, appearance) and posterior segments (eg, vessel changes, exudates, hemorrhages)
|Ears, Nose, Mouth, and Throat|
- External inspection of ears and nose (eg, overall appearance, scars, lesions, masses)
- Otoscopic examination of external auditory canals and tympanic membranes
- Assessment of hearing (eg, whispered voice, finger rub, tuning fork)
- Inspection of nasal mucosa, septum, and turbinates
- Inspection of lips, teeth, and gums
- Examination of oropharynx: oral mucosa, salivary glands, hard and soft palates, tongue, tonsils, and posterior pharynx
- Examination of neck (eg, masses, overall appearance, symmetry, tracheal position, crepitus)
- Examination of thyroid (eg, enlargement, tenderness, mass)
- Assessment of respiratory effort (eg, intercostal retractions, use of accessory muscles, diaphragmatic movement)
- Percussion of chest (eg, dullness, flatness, hyperresonance)
- Palpation of chest (eg, tactile fremitus)
- Auscultation of lungs (eg, breath sounds, adventitious sounds, rubs)
- Palpation of heart (eg, location, size, thrills)
- Auscultation of heart with notation of abnormal sounds and murmurs
- carotid arteries (eg, pulse amplitude, bruits)
- abdominal aorta (eg, size, bruits)
- femoral arteries (eg, pulse amplitude, bruits)
- pedal pulses (eg, pulse amplitude)
- extremities for edema and/or varicosities
- Inspection of breasts (eg, symmetry, nipple discharge)
- Palpation of breasts and axillae (eg, masses or lumps, tenderness)
- Examination of abdomen with notation of presence of masses or tenderness
- Examination of liver and spleen
- Examination for presence or absence of hernia
- Examination of anus, perineum, and rectum, including sphincter tone, presence of hemorrhoids, rectal masses
- Obtain stool sample for occult blood test when indicated
- Examination of the scrotal contents (eg, hydrocele, spermatocele, tenderness of cord, testicular mass)
- Examination of the penis
- Digital rectal examination of prostate gland (eg, size, symmetry, nodularity, tenderness)
Pelvic examination (with or without specimen collection for smears and cultures), including
- Examination of external genitalia (eg, general appearance, hair distribution, lesions) and vagina (eg, general appearance, estrogen effect, discharge, lesions, pelvic support, cystocele, rectocele)
- Examination of urethra (eg, masses, tenderness, scarring)
- Uterus (eg, size, contour, position, mobility, tenderness, consistency, descent or support)
- Adnexa/parametria (eg, masses, tenderness, organomegaly, nodularity)
- Examination of bladder (eg, fullness, masses, tenderness)
- Cervix (eg, general appearance, lesions, discharge)
- Uterus (eg, size, contour, position, mobility, tenderness, consistency, descent or support)
- Adnexa/parametria (eg, masses, tenderness, organomegaly, nodularity)
|Lymphatic||Palpation of lymph nodes in two or more areas:|
- Examination of gait and station
- Inspection and/or palpation of digits and nails (eg, clubbing, cyanosis, inflammatory conditions, petechiae, ischemia, infections, nodes)
Examination of joints, bones, and muscles of one or more of the following six areas: (1) head and neck; (2) spine, ribs, and pelvis; (3) right upper extremity; (4) left upper extremity; (5) right lower extremity; and (6) left lower extremity. The examination of a given area includes:
- 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
- Assessment of stability with notation of any dislocation (luxation), subluxation, or laxity
- Assessment of muscle strength and tone (eg, flaccid, cog wheel, spastic) with notation of any atrophy or abnormal movements
- Inspection of skin and subcutaneous tissue (eg, rashes, lesions, ulcers)
- Palpation of skin and subcutaneous tissue (eg, induration, subcutaneous nodules, tightening)
- Test cranial nerves with notation of any deficits
- Examination of deep tendon reflexes with notation of pathological reflexes (eg, Babinski)
- Examination of sensation (eg, by touch, pin, vibration, proprioception)
- Description of patient's judgment and insight
Brief assessment of mental status including:
- Orientation to time, place, and person
- Recent and remote memory
- Mood and affect (eg, depression, anxiety, agitation)
Table 28-7 Levels of 1997 Physical Examination ||Download (.pdf)
Table 28-7 Levels of 1997 Physical Examination
|Level of Exam||Performance and Documentation|
|Problem-Focused||1 to 5 elements identified by a bullet.|
|Expanded Problem-Focused||At least 6 elements identified by a bullet.|
|Detailed||At least 2 elements identified by a bullet from each of 6 areas/systems OR at least 12 elements identified by a bullet in 2 or more areas/systems.|
|Comprehensive||Perform all elements identified by a bullet in at least 9 organ systems or body areas and document at least 2 elements identified by a bullet from each of 9 areas/systems.|
Determining Level of Service
For both the 1995 and 1997 guidelines, assign a specific level to each of the three key components. Rate history and examination each as either problem-focused, expanded problem-focused, detailed, or comprehensive. Rate the complexity of MDM as either straightforward, low, moderate, or high. CPT correlates specific levels of the key components with certain levels of most E/M services.
Initial patient encounters (initial hospital care, CPT 99221-99223; initial observation care, CPT 99218-99220; consultations, 99241-99245 and 99251-99255) require consideration of all three key components. Consider only two of the key components for subsequent hospital (CPT 99231-99233) or observation visits (CPT 99224-99226). The lowest component of the two or three key components required determines the visit level. For example, a level three initial hospital service (CPT 99223) includes a comprehensive history, comprehensive exam, and high-complexity decision making (Table 28-8). If the documentation merely supports a detailed level of history, yet meets the requirements for a comprehensive examination and high-complexity decision making, report only a level one initial hospital service (CPT 99221). In contrast, if a subsequent hospital visit note contains a complete examination and high-complexity MDM, then report CPT 99233 and history need not even be considered. When selecting visit levels for services that only consider two key components, MDM should be one of those two key components. While not stated in the documentation guidelines, medical necessity underlies every physician service and is most appropriately demonstrated through MDM. Reporting subsequent services with MDM as a key component thereby precludes the allegation of an unwarranted high-level subsequent encounter based upon merely a comprehensive history and examination (eg, common cold).
Table 28-8 Levels of Initial Hospital Care ||Download (.pdf)
Table 28-8 Levels of Initial Hospital Care
|Initial Hospital Care||History||Examination||MDM||Time|
|99221||Detailed or comprehensive||Detailed or comprehensive||Straightforward or low||30 min|
Time Counseling/Coordinating Care
CPT assigns most E/M codes a typical time to render a service, but importantly, the service duration need not last that length. For inpatient services, time accrues as unit or floor time in addition to face-to-face time. When more than 50% of the total service time involves counseling and/or coordination of care, the provider may select a code reflecting the total time spent with the patient, rather than the three key components. Time and the corresponding counseling details must be documented in the medical record when selecting the E/M code on the basis of time (eg, “25 of 40 minutes spent urging the patient to undergo a diagnostic biopsy”). Of course, record patient responses to counseling and all relevant history, examination, and MDM as necessary for good patient care.