Portsmouth Virginia
Best answers
Question -

There has been some debate on two items relating to E/M coding and I would love feedback that may help me to not only educate myself but my physicians and colleagues...

1. Medical Decision Making - we utilize the 1999 Table of Risk - but there is some debate in determining what medications constitute a level 3 vice a level 4 for complexity (I am speaking in terms of established patients in this instance). If a pt has hx of URI's and is in the office today with another and we prescribe an antibiotic, albuterol inhaler and motrin for fever and pain - the exam is a 3 but the history is a 4 (almost a 5) - which way do you sway with MDM??

2. If a patients past (active) medical history is documented in PFSH on a SOAP note - (i.e. pt has DM; CAD; HTN) but the physician is managing a complaint of chest pain and doesn't manage medications or anything pertaining to those PFSH elements - can you still use them to relieve the HPI statement? Can 3 chronic illness mentioned in PFSH only take the place of a 4+ point HPI statement????

Just looking for some opinions or even a place to find more definitive explanation of these two items....

Any thoughts, comments or insight is greatly appreciated!!

Angela N. Andersen, CPC
My understanding of the MDM table found on page 46 in the 1997 Documentation Guidelines, is that you need to determine the number of diagnoses or management options, the amount and/or complexity of data to be reviewed, and then look at the risk as found in the Table of Risk. Anytime you are managing medications you start at a "moderate level. Your MDM has to meet or exceed at least two of the three elements in the table. You will be either at a level 3 or level 4 for your MDM based on the documentaion.

As to your second question, that is also answered in the 1997 Documentation Guidelines. In those guidelines was when they determined that reference to three stable chronic conditions is equivalent to 4 elements of the HPI. This way you can get an extended HPI on your establised patients just by reviewing their chronic conditions.

If you don't have a copy of the 1997 guidelines you can download it from the CMS website.
We recently updated our protocol for established patient E&M services--although only 2 out of 3 of the key components are required, we decided that Medical Decision Making should always be required as one of the two key components (so you can go by Exam & MDM, or History & MDM, but not just by History & Exam to determine your E&M level). This was based on the fact that we received a significant amount of literature regarding the importance of Complexity & Medical Decision Making when choosing levels for E&M services.

For the patient w/URI's, the overall level of MDM would depend on if it's a new problem to the examiner (I know you said the patient has a history of URI's, but was this just a follow-up to a recent URI, or a new URI altogether?), & if any tests or treatments were ordered (e.g. strep screen, nebulizer treatment, etc.). If it was a new problem with the prescription drug, + a Detailed History, I would audit it out to 99214.

Re. the second question, I would have to see the note. Did the provider document the status of each of the 3 chronic conditions? If so, that would count as a Detailed HPI. If not, you could count it as part of the patient's past medical history, or 1 history area. To "bypass" the HPI requirements, you would need the status of each chronic condition (e.g. HTN--improved w/med.), not just a list of the conditions.