Part B Insider (Multispecialty) Coding Alert

Published on Tue May 10, 2011 PDF

Question: Our physician often sees patients who come in with a long list of problems that are often stable. For such a visit, should I use a lower-level E/M?

Answer: Such visits can actually involve more history and medical decision making than you may give yourself credit for and may ultimately support a higher-level office visit. You're  often determining whether prescription medication is working (moderate risk related to medical decision making).

Key: When treating chronic conditions, think 1997 E/M guidelines. These count documentation of the status of one to two chronic conditions as an expanded problemfocused history of present illness (HPI) and recording the status of three or more chronic conditions as acomprehensive HPI.

Example: You see a patient for follow-up of medical problems (chief complaint). In the HPI, you note, "The 63-year-old female with hypertension. Blood pressure has been controlled. Denies headaches. Her back pain is stable, but she still has minor tingling after sitting for long periods. Her osteoporosis is now stable. Recent bone density test showed no further deterioration."

Under assessment/plan, you note the conditions' status as:

• Hypertension, stable, continue meds
• Back pain, stable, continue meds
• Osteoporosis, stable, continue meds.

For the remaining history, you document under past medical family social history (PFSH) that the patient is "not exercising" (1 SH, pertinent). The HPI includes three elements of ROS, which counts as extended ROS. Expanded problem- focused HPI + extended ROS + pertinent PFSH = detailed history.

Your exam includes the constitutional, cardiovascular, and musculoskeletal systems, making it an expanded problem-focused exam.

Under medical decision making, (MDM) you have three stable problems (three points) and review of radiology test (one point). The three chronic conditions and prescription drug management point to a moderate level of risk, giving you multiple diagnoses, moderate risk, and low data, which supports moderate complexity MDM. This level MDM combined with detailed history and expanded problem-focused exam supports a level-four established patient visit (such as 99214).