Internal Medicine Coding Alert

Published on Tue Apr 14, 2009 PDF

Question: A patient comes in with a chief complaint of increasing forgetfulness. How could I apply the mini mental status exam (MMSE) into the history components history of present illness (HPI)? Should I count it as context? Or could it be part of the E/M levels medical decision making (MDM)?

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Answer: The MMSE could count in all of these -- chief complaint, HPI, ROS,physical examination, and MDM.

Under HPI, a description of patients increasing forgetfulness could be detailed under multiple parts of the HPI including context, quality, severity, duration, and associated signs and symptoms. Context is a description of where the patient is orwhat he is doing when the signs or symptoms begin. A context note could indicate the forgetfulness has increased since the patient fell from the porch, for instance.

Quality is a characteristic of the symptom. Severity involves a measure, such as on a scale, of how bad the complaint is. Duration is how long the forgetfulness has been occurring. Then you could consider any associated, secondary complaints part of associated signs and symptoms.

Additional information relating to the patients neurological and psychiatric issues could be captured in the ROS.

MMSE performance and documentation may contribute to the encounters exam and MDM level. Both the 1995 and 1997 guidelines allow for this under organ system.When selecting the MDM level, your physician could include how the MMSEs resultsimpacted his assessment of the patients condition and his recommendations for additional data (for instance, tests ordered) or management options.

-- Answers to You Be the Coder and Reader Questions were reviewed by Bruce Rappoport, MD, CPC, CHCC, a board-certified internist and medical director of Broward Healths Best Choice Plus and Total Claims Administration in Fort Lauderdale, Fla.