The 3 Key Components of E/M Coding: History, Exam, Medical Decision Making

Evaluation and management coding is a type of medical coding used by physicians and certain other healthcare providers to report their services as part of medical billing. Evaluation and management (E/M) codes are found in the CPT® code set in the range 99201-99499 and cover a variety of services. Many of the most commonly reported E/M codes, such as those for office visits and inpatient care, include a combination of patient history, examination, and medical decision making (MDM).

These factors — history, exam, and MDM — are the three key components of E/M level selection. Determining the correct type of history, exam, and MDM can feel intimidating even for seasoned coders because of the many requirements involved. A solid understanding of these three key components will help ensure more accurate coding and reimbursement for E/M codes.

Basic Steps to Select an E/M Code Using Key Components

The following is an overview of how a provider selects an E/M code using the three key components of history, exam, and MDM. Different services may require different steps, such as when you report an E/M encounter based on time, but this scenario will give you a sense of the general process used to code many E/M visits. The rest of the article will provide details on how to complete each step.

For this example, a physician sees a new patient for an E/M office visit. To report the rendered service, the physician must review the requirements for E/M codes 99201-99205, which the CPT® code set labels as New Patient Office or Other Outpatient Services. The physician follows the steps below to determine the appropriate E/M code from that group using the three key components.

1. Determine the type of history. A patient history includes getting the chief complaint and the history of the present illness. The history also may include a review of body systems using questions to identify signs and symptoms, and a review of the patient’s past, family, and social history, depending on what’s medically appropriate for the visit. The amount of history taken will determine the type: problem focused, expanded problem focused, detailed, or comprehensive.

2. Determine the type of the physical exam. The provider uses clinical judgment to determine the extent of physical examination needed for each of the patient’s body areas and organ systems. The provider will document one of these four types of exam: problem focused, expanded problem focused, detailed, or comprehensive.

3. Determine the type of medical decision making (MDM). MDM is how the provider rates the degree of difficulty in establishing a patient’s diagnosis and treatment plan. E/M codes include four types of MDM: straightforward, low complexity, moderate complexity, and high complexity.

4. Determine the final code. Once the provider has determined the types of history, exam, and MDM, final E/M code selection can occur based on those three key components. For this example, assume the physician performed a comprehensive history, a comprehensive exam, and medical decision making of high complexity for this new patient. The appropriate code in this case is 99205 Office or other outpatient visit for the evaluation and management of a new patient, which requires these 3 key components: A comprehensive history; A comprehensive examination; Medical decision making of high complexity ….

E/M History Component: General Overview

The first key component for E/M coding is history. As noted above, there are four types:

  • Problem focused;
  • Expanded problem focused;
  • Detailed; and
  • Comprehensive.

A small number of E/M code descriptors, specifically those for subsequent hospital care and subsequent nursing facility care, add the term “interval” before the type of history, such as “a comprehensive interval history.” Interval history is a history that focuses on the period since the patient’s last assessment, according to the January 2000 CPT® Assistant newsletter, an authoritative publication by the American Medical Association (AMA).

To determine the type of history for an E/M code, you must be aware of these four elements:

  • Chief complaint;
  • History of present illness;
  • System review (also called review of systems); and
  • Past, family, and/or social history.

The chief complaint (CC) is a brief statement explaining the reason for the encounter, such as the symptom, problem, condition, or diagnosis. Each of the four history types requires a chief complaint.

The other elements require more explanation, which you’ll find below. As part of the explanations, you’ll see references to the CPT® E/M guidelines, which are the official guidelines published with the CPT® code set. You’ll also see information from the Centers for Medicare & Medicaid Services (CMS) 1995 and 1997 Documentation Guidelines for Evaluation and Management Services. Many payers other than Medicare have adopted the 1995 and 1997 Documentation Guidelines, so familiarity with both the CPT® and CMS guidelines is essential to accurate coding and reporting.

E/M History Component: History of Present Illness

History of present illness (HPI) is the portion of the E/M history component that describes the patient’s current illness. HPI covers development of the illness from the first sign or symptom to the current time.

The CPT® guidelines for the E/M section list these elements for HPI: location, quality, severity, timing, context, modifying factors, and associated signs and symptoms with a significant relationship to the presenting problem or problems. The CMS 1995 and 1997 Documentation Guidelines add duration to this list.

According to CPT® E/M guidelines, HPI may be brief or extended. The CMS 1995 and 1997 Documentation Guidelines help define these terms.

  • 1995 Documentation Guidelines: A brief HPI describes one to three elements from the list, such as location, quality, and severity. An extended HPI consists of four or more elements.
  • 1997 Documentation Guidelines: Again, a brief HPI includes one to three elements, but the 1995 and 1997 Documentation Guidelines differ for extended HPI. The 1997 Documentation Guidelines state an extended HPI is at least four elements OR the status of at least three chronic or inactive conditions. For more on this option from the 1997 Documentation Guidelines, see the section E/M History Component: Extended HPI and Chronic Conditions.

The CMS MLN Evaluation and Management Services guide provides this example of a brief HPI for a patient with a chief complaint of earache: “Dull ache in left ear over the past 24 hours.” This brief HPI includes the three elements of quality (dull ache), location (in left ear), and duration (over the past 24 hours).

E/M History Component: Review of Systems

System review, or review of systems (ROS), is the part of an E/M history that involves asking about body systems to identify past and present signs and symptoms. A series of questions helps define the problem, clarify the differential diagnosis, identify testing needed, and provide baseline data about body systems related to treatment options.

The body systems listed by both the CPT® guidelines and CMS 1995 and 1997 Documentation Guidelines are the same and are shown below.

Body Systems for ROS in E/M Coding

  • Constitutional symptoms (fever, weight loss, etc.)
  • Eyes
  • Ears, nose, mouth, and throat
  • Cardiovascular
  • Respiratory
  • Gastrointestinal
  • Genitourinary
  • Musculoskeletal
  • Integumentary (skin and/or breast)
  • Neurological
  • Psychiatric
  • Endocrine
  • Hematologic/lymphatic
  • Allergic/immunologic

ROS may be problem pertinent, extended, or complete. The 1995 and 1997 Documentation Guidelines define these terms:

  • Problem pertinent ROS is about the system directly related to the problems noted in the HPI. Documentation should include the patient’s positive and negative responses to questions about the body system.
  • Extended ROS includes responses about two to nine systems.
  • Complete ROS requires review of at least 10 systems. The record should include individual documentation of systems with positive responses and negative responses that are relevant to the encounter. For the other systems, Medicare allows a note of “all other systems are negative.”

The CMS Evaluation and Management Services guide includes this example of a complete ROS for a patient with a chief complaint of “fainting spell.” There are 10 systems documented in this complete ROS example.

Constitutional: Weight stable, + fatigue.

Eyes: + loss of peripheral vision.

Ear, nose, mouth, throat: No complaints.

Cardiovascular: + palpitations; denies chest pain; denies calf pain, pressure, or edema.

Respiratory: + shortness of breath on exertion.

Gastrointestinal: Appetite good, denies heartburn and indigestion. + episodes of nausea. Bowel movement daily; denies constipation or loose stools.

Urinary: Denies incontinence, frequency, urgency, nocturia, pain, or discomfort.

Skin: + clammy, moist skin.

Neurological: + fainting; denies numbness, tingling, and tremors.

Psychiatric: Denies memory loss or depression. Mood pleasant.

E/M History Component: Past, Family, and/or Social History

Past, family, and/or social history (PFSH) for E/M coding may be categorized as either pertinent or complete. As the PFSH name implies, this part of the E/M history component is a review of one or more of these three areas:

  • Past history is a review of the patient’s previous illnesses, injuries, and treatments including operations and hospitalizations. Despite the term “past history,” the CPT® E/M guidelines also include a listing of current medications in this category, along with allergies (such as to drugs or food), and age-appropriate immunization and feeding/dietary status.
  • Family history is a review of medical events in the patient’s family, including the health status or cause of death for parents, siblings, and children. This category also includes family experience with diseases related to the patient’s chief complaint, HPI, or ROS; hereditary diseases; and diseases of family members that put the patient at risk.
  • Social history is a review of past and current activities. Relevant information may vary by age, such as marital status and living arrangements; current employment; occupational history; military history; drug, alcohol, and tobacco use; education level; sexual history; and other relevant social factors.

Pertinent PFSH is a review of areas related to the problems noted in the HPI. One item from any of the three areas will qualify as pertinent PFSH, according to the 1995 and 1997 Documentation Guidelines.

Complete PFSH is a review of two or all three of the areas. Whether you need two or three depends on the E/M service category, the 1995 and 1997 Documentation Guidelines state:

  • One item from two areas is a complete PFSH for established patient office and outpatient services, emergency department, established patient domiciliary care, and established patient home care.
  • One item from all three areas is a complete PFSH for new patient office and outpatient services, hospital observation services, initial hospital inpatient care, consultations, comprehensive nursing facility assessments, new patient domiciliary care, and new patient home care.

A pertinent PFSH example from the CMS Evaluation and Management Services guide shows what review of relevant past surgical history for a patient with coronary artery disease might look like: “Patient returns to office for follow-up of coronary artery bypass graft in 1992. Recent cardiac catheterization demonstrates 50 percent occlusion of vein graft to obtuse marginal artery.”

E/M categories that require only an interval history (subsequent hospital care and subsequent nursing facility care) don’t require PFSH, according to the CMS Evaluation and Management Services guide.

E/M History Component: Determine the Type of History

Once you’ve determined the level of HPI, ROS, and PFSH, you can select the correct type of history for your E/M code using Table 1, taken from the CMS Evaluation and Management Services guide. You must meet all the elements in a row to qualify for that type of history.

Table 1: Elements Required for Each Type of E/M History*
*Meet all elements in a row to qualify for that history type

Type of History CC HPI ROS PFSH
Problem Focused Required Brief N/A N/A
Expanded Problem Focused Required Brief Problem Pertinent N/A
Detailed Required Extended Extended Pertinent
Comprehensive Required Extended Complete Complete

E/M History Component: Extended HPI and Chronic Conditions

Earlier, this article mentioned that the 1995 Documentation Guidelines require the medical record to include four or more elements for an extended HPI, such as location, quality, severity, and timing. The 1997 Documentation Guidelines require either four elements of the HPI or ― and this is the important difference — the status of three or more chronic or inactive conditions. Because of this rule difference, the 1997 Documentation Guidelines might result in coding a higher-level E/M service than the 1995 Documentation Guidelines for encounters that involve chronic conditions, such as periodic prescription renewals.

Here is an example of using the 1997 Documentation Guidelines to reach an extended HPI. Suppose a Medicare patient who has controlled benign hypertension, controlled type 2 diabetes, and elevated cholesterol and triglycerides presents for a follow-up of his conditions. After an appropriate exam, the provider renews the patient’s prescriptions and notes the following:

  • Hypertension is active, stable with current medication renewed.
  • Diabetes is active, stable on metformin 500 mg b.i.d., renewed.
  • Mixed hyperlipidemia is active, stable with current medication renewed.

Because the provider indicates the status of at least three chronic or inactive conditions, using the 1997 Documentation Guidelines leads to an extended HPI. Looking at Table 2 above, you can see that an extended HPI could contribute to a detailed or comprehensive history, assuming the visit meets the required levels for the CC, ROS, and PFSH. If using the 1995 Documentation Guidelines resulted in only a brief HPI for our example, then expanded problem focused is the highest level of history the encounter could reach. This difference in history type could determine whether you will report 99213, which includes an expanded problem focused history, or higher-level codes 99214 (detailed history) or 99215 (comprehensive history). Higher level E/M codes pay more, so determining the correct level of E/M history is important to ensuring adequate reimbursement.

E/M Exam Component: Body Areas and Organ Systems

The next key component for E/M coding after history is the physical examination. CPT® E/M guidelines list four types of examination:

  • Problem focused;
  • Expanded problem focused;
  • Detailed; and
  • Comprehensive.

The 1995 and 1997 Documentation Guidelines from CMS use those terms for exam types, too, but the guidance they offer on what’s required for each level differs. The exam component is one of the major areas of difference between the two sets of CMS Documentation Guidelines.

Before we explore the different exam types, it’s helpful to know the body areas and organ systems involved. First are the lists referenced by the CPT® E/M guidelines and the 1995 E/M Documentation Guidelines.

Body Areas for Exams in E/M Coding (CPT® Guidelines and 1995 Documentation Guidelines)

  • Head, including the face
  • Neck
  • Chest, including breasts and axilla
  • Abdomen
  • Genitalia, groin, buttocks
  • Back (the 1995 Documentation Guidelines add “including spine”)
  • Each extremity

Organ Systems for Exams in E/M Coding (CPT® Guidelines and 1995 Documentation Guidelines)

  • Constitutional (e.g., vital signs, general appearance) (this bullet is in the 1995 Documentation Guidelines only, not in CPT® guidelines)
  • Eyes
  • Ears, nose, mouth, and throat
  • Cardiovascular
  • Respiratory
  • Gastrointestinal
  • Genitourinary
  • Musculoskeletal
  • Skin
  • Neurologic
  • Psychiatric
  • Hematologic/lymphatic/immunologic

The 1997 Documentation Guidelines state instead that the exams types apply to general multi-system exams and the single organ systems listed below.

Single Organ Systems for Exams in E/M Coding (1997 Documentation Guidelines)

  • Cardiovascular
  • Ears, nose, mouth, and throat
  • Eyes
  • Genitourinary (female)
  • Genitourinary (male)
  • Hematologic/lymphatic/immunologic
  • Musculoskeletal
  • Neurological
  • Psychiatric
  • Respiratory
  • Skin

E/M Exam Component: Definitions of the 4 Types

The 1995 and 1997 E/M Documentation Guidelines take the definitions for examination types from the CPT® E/M guidelines and then expand on them. Below you’ll find an overview, but the information shown for the 1997 Documentation Guidelines applies to multi-system exams only. The 1997 Documentation Guidelines provide an additional 25 pages of specific requirements for single organ system exams, and you should review the guidelines document for that information.

A problem focused examination is a limited examination of the affected body area or organ system (one body area or organ system), according to the 1995 E/M Documentation Guidelines.

The 1997 E/M Documentation Guidelines state a multi-system problem focused exam involves performing and documenting one to five elements identified by a bullet in Table 2 below.

An expanded problem focused examination is a limited examination of the affected body area or organ system and other symptomatic or related organ system(s) (two to seven body areas or organ systems), according to the 1995 E/M Documentation Guidelines.

The 1997 E/M Documentation Guidelines state that an expanded problem focused exam consists of performing and documenting at least six elements identified by a bullet in Table 2 for a multi-system exam.

A detailed examination is an extended examination of the affected body area(s) and other symptomatic or related organ system(s) (two to seven body areas or organ systems with at least one body area examined in more detail), under the 1995 E/M Documentation Guidelines.  The similarity between the 1995 detailed and expanded problem focused exam requirements has caused confusion for coders.

The 1997 E/M Documentation Guidelines tried to provide more distinct requirements for the detailed exam, calling for performance and documentation of at least two elements identified by a bullet from each of six areas/systems OR at least 12 elements identified by a bullet in two or more areas/systems for the general multi-system exam. See Table 2 for bullets.

A comprehensive examination is a complete general multi-system examination (eight or more organ systems) or a complete examination of a single organ system, the 1995 E/M Documentation Guidelines state. The guidelines neglect, however, to specifically define what constitutes a single-system comprehensive exam.

The 1997 E/M Documentation Guidelines indicate that a comprehensive general multi-system exam should include at least nine organ systems or body areas. For each system or area chosen, the provider should perform all elements of the examination identified by a bullet in Table 2, “unless specific directions limit the content of the examination.” For each area or system, “documentation of at least two elements identified by a bullet is expected.”

Table 2: 1997 E/M Documentation Guidelines General Multi-System Examination

System/Body Area Elements of Examination

Constitutional

  • Measurements 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 the patient (e.g., development, nutrition, body habitus, deformities, attention to grooming)

Eyes

  • Inspection of conjunctivae and lids
  • Examination of pupils and irises (e.g., reaction to light and accommodation, size and symmetry)
  • Ophthalmoscopic examination of optic discs (e.g., size, C/D ratio, appearance) and posterior segments (e.g., vessel changes, exudates, hemorrhages)

Ear, Nose, Mouth, and Throat

  • External inspection of ear and nose (e.g., overall appearance, scars, lesions, masses)
  • Otoscopic examination of external auditory canals and tympanic membranes
  • Assessment of hearing (e.g., 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

Neck

  • Examination of neck (e.g., masses, overall appearance, symmetry, tracheal position, crepitus)
  • Examination of thyroid (e.g., enlargement, tenderness, mass)

Respiratory

  • Assessment of respiratory effort (e.g., intercostal retractions, use of accessory muscles, diaphragmatic movement)
  • Percussion of chest (e.g., dullness, flatness, hyperresonance)
  • Palpation of chest (e.g., tactile fremitus)
  • Auscultation of lungs (e.g., breath sounds, adventitious sounds, rubs)

Cardiovascular

  • Palpation of heart (e.g., location, size, thrills)
  • Auscultation of heart with notation of abnormal sounds and murmurs

Examination of:

  • carotid arteries (e.g., pulse, amplitude, bruits)
  • abdominal aorta (e.g., size, bruits)
  • femoral arteries (e.g., pulse, amplitude, bruits)
  • pedal pulses (e.g., pulse, amplitude)
  • extremities for edema and/or varicosities

Chest (Breasts)

 

  • Inspection of breasts (e.g., symmetry, nipple discharge)

  • Palpation of breasts and axillae (e.g., masses or lumps, tenderness)

Gastrointestinal (Abdomen)

  • Examination of abdomen with notation of presence of masses or tenderness
  • Examination of liver and spleen
  • Examination for presence or absence of hernia
  • Examination (when indicated) of anus, perineum and rectum, including sphincter tone, presence of hemorrhoids, rectal masses
  • Obtain stool sample for occult blood test when indicated

Genitourinary

MALE:

  • Examination of the scrotal contents (e.g., hydrocele, spermatocele, tenderness of cord, testicular mass)
  • Examination of the penis
  • Digital rectal examination of prostate gland (e.g., size, symmetry, nodularity, tenderness)

FEMALE:

Pelvic examination (with or without specimen collection for smears and cultures), including

  • Examination of external genitalia (e.g., general appearance, hair distribution, lesions) and vagina (e.g., general appearance, estrogen effect, discharge, lesions, pelvic support, cystocele, rectocele)
  • Examination of urethra (e.g., masses, tenderness, scarring)
  • Examination of bladder (e.g., fullness, masses, tenderness)
  • Cervix (e.g., general appearance, lesions, discharge)
  • Uterus (e.g., size, contour, position, mobility, tenderness, consistency, descent or support)
  • Adnexa/parametria (e.g., masses. tenderness, organomegaly, nodularity)

Lymphatic

    Palpation of lymph nodes in two or more areas:

  • Neck
  • Axillae
  • Groin
  • Other

Musculoskeletal

  • Examination of gait and station
  • Inspection and/or palpation of digits and nails (e.g., 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, 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 (e.g., flaccid, cog wheel, spastic) with notation of any atrophy or abnormal movements

Skin

 

  • Inspection of skin and subcutaneous tissue (e.g., rashes, lesions, ulcers)
  • Palpation of skin and subcutaneous tissue (e.g., induration, subcutaneous nodules, tightening)

Neurologic

 

  • Test cranial nerves with notation of any deficits
  • Examination of deep tendon reflexes with notation of pathological reflexes (e.g., Babinski)
  • Examination of sensation (e.g., by touch, pin, vibration, proprioception)

Psychiatric

  • 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 (e.g., depression, anxiety, agitation)

E/M MDM Component: Elements to Determine Type

The final key component for E/M coding is medical decision making, or MDM. Like the other key components of history and exam, there are four types of MDM:

  • Straightforward;
  • Low complexity;
  • Moderate complexity; and
  • High complexity.

To determine the type of MDM, you must consider three factors:

  • The number of diagnoses and/or management options that the provider must consider;
  • The amount and/or complexity of medical records, diagnostic tests, and/or other data the provider must get, review, and analyze; and
  • The risk of complications, morbidity, comorbidities, and/or mortality associated with the patient’s presenting problem(s), diagnostic procedure(s), and/or management options.

Table 3 shows how those elements help you arrive at the type of MDM. You can find versions of this table in the CPT® E/M guidelines and in the 1995 and 1997 Documentation Guidelines.

Table 3: Elements Required for Each Type of MDM in E/M Coding*
* Meet or exceed 2 of 3 elements in a row to qualify for that MDM type

Number of Diagnoses or Management Options Amount and/or Complexity of Data to Be Reviewed Risk of Complications and/or Morbidity or Mortality Type of Decision Making
Minimal Minimal or None Minimal Straightforward
Limited Limited Low Low Complexity
Multiple Moderate Moderate Moderate Complexity
Extensive Extensive High High Complexity

You must have two out of the three MDM components meet or exceed the levels listed in the row to assign that type of MDM. For example, if the number of diagnoses is minimal, but the amount of data and level of risk are both moderate, your MDM type is moderate complexity because you have met two of the three requirements for that MDM type.

Unlike the history and exam components, the 1995 and 1997 Documentation Guidelines don’t provide specifics on the requirements for each type of MDM. Consequently, many practices and payers use a tool like the Marshfield point system to make the process more precise. But when you’re using point tools like that, you should follow your payer’s specific rules and score sheets, and rely on official guidelines when making your final E/M code choice.

E/M MDM Component: Number of Diagnoses and Management Options

The first element of MDM is the number of diagnoses and management options that the provider considers. The 1995 and 1997 Documentation Guidelines offer general advice, indicating that a diagnosed problem or one that is improving or resolved is less complex than an undiagnosed problem or one that is getting worse. The guidelines also state that the number and type of diagnostic tests and the need to seek advice can also be indicators of how complex a problem is. 

The Marshfield tool tried to provide a more definite approach to selecting the level for this MDM element by using a version of the point system below.

  • Self-limited/minor problem: 1 point each, with a max of 2 points
  • Established problem (to the provider), improving/stable: 1 point each
  • Established problem (to the provider), worsening: 2 points each
  • New problem (to the provider), no planned additional workup: 3 points each, max of 3 points
  • New problem (to the provider), additional workup: 4 points each

After adding up the points, you translate them to the levels identified in Table 3 in the column for Number of Diagnoses or Management Options.

  • 1 point: minimal
  • 2 points: limited
  • 3 points: multiple
  • 4 points: extensive

E/M MDM Component: Data Complexity

The second element to consider when determining MDM type is the amount and complexity of data related to the encounter. The 1995 and 1997 Documentation Guidelines indicate that the decision to review old medical records, the types of diagnostic tests ordered, and the method of test review can indicate the level of complexity.

Your point tool is likely to provide a list similar to the one below to help you calculate this MDM element.

  • Review and/or order of clinical lab tests: 1 point total
  • Review and/or order of tests in radiology section: 1 point total
  • Review and/or order of tests in medicine section: 1 point total
  • Discussion of test results with performing physician: 1 point total
  • Decision to obtain old records or the history from someone other than the patient: 1 point total
  • Review and summary of old records or obtaining history from someone other than patient or discussion of case with another healthcare provider: 2 points total
  • Independent visualization of image, tracing, or specimen itself (not simply review of report): 2 points total

You will score the complexity of data by adding the points and selecting the correct level for this element from Table 3.

  • 0-1 point: minimal or none
  • 2 points: limited
  • 3 points: moderate
  • 4 or more points: extensive

E/M MDM Component: Risk

The last of the three MDM elements, level of risk, involves three categories: presenting problem, diagnostic procedures ordered, and management options. The highest score from any one of the three categories (not from each category) determines the patient’s risk level of minimal, low, moderate, or high, according to the 1995 and 1997 Documentation Guidelines.

Both sets of CMS guidelines state “the determination of risk is complex and not readily quantifiable,” but the 1995 and 1997 Documentation Guidelines do offer some help in the form of a Table of Risk (see Table 4). The Table of Risk includes common clinical examples to demonstrate what each level might involve. When you’re using the Table of Risk, risk assessment for the presenting problem is based on what’s anticipated for the disease process between the current encounter and the next one. Risk assessment for diagnostic testing and management options is based on risk during and immediately after those services.

Table 4: MDM Table of Risk for E/M Coding*
* The highest level of risk in any 1 column determines overall risk

Level of Risk Presenting Problem(s) Diagnostic Procedure(s) Ordered Management Options Selected

Minimal

One self-limited or minor problem, e.g., cold, insect bite, tinea corporis

Laboratory tests requiring venipuncture 

Chest X-rays 

EKG/EEG

Urinalysis

Ultrasound, e.g., echocardiography

KOH prep

Rest

Gargles

Elastic bandages

Superficial dressings

Low

Two or more self-limited or minor problems

One stable chronic illness, e.g., well controlled hypertension, non-insulin dependent diabetes, cataract, BPH

Acute uncomplicated illness or injury, e.g., cystitis, allergic rhinitis, simple sprain

Physiologic tests not under stress, e.g., pulmonary function tests

Non-cardiovascular imaging studies with contrast, e.g., 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

Moderate

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, e.g., lump in breast

Acute illness with systemic symptoms, e.g., pyelonephritis, pneumonitis, colitis

Acute complicated injury, e.g., head injury with brief loss of consciousness

Physiologic tests under stress, e.g., 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, e.g., arteriogram, cardiac catheterization

Obtain fluid from body cavity, e.g. 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

High

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, e.g., 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

Discography

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

Final Summary for E/M Coding Based on 3 Key Components

The beginning of this article included the example of a physician performing an E/M service reported using 99205 Office or other outpatient visit for the evaluation and management of a new patient, which requires these 3 key components: A comprehensive history; A comprehensive examination; Medical decision making of high complexity ….

As you have now seen, choosing that E/M code requires a number of steps to determine the type for each of the three key components:

  • Comprehensive history: The documentation has to show a chief complaint, an extended HPI, a complete ROS, and a complete PFSH to reach a comprehensive history. Determining the level of each of those elements requires separate steps of their own, counting the number of HPI elements, body systems reviewed, and PFSH areas reviewed.
  • Comprehensive examination: To reach the highest level of exam, the person who is coding must determine whether a general multi-system exam or a single organ system exam was performed. Whether to follow the 1995 or 1997 Documentation Guidelines is another factor to consider. Then the coder must compare the documentation to the organ and body system checklists in the guidelines to be sure the exam reached the minimum requirements for a comprehensive exam, such as eight organ systems for the 1995 Documentation Guidelines or two elements from nine organ systems or body areas for the 1997 Documentation Guidelines.
  • MDM of high complexity: For high complexity MDM, the medical record must show the visit met two of the three requirements for that level: an extensive number of diagnoses or management options, an extensive amount of data to review, and a high risk of complications. Calculating each of those levels requires yet another layer of applying of E/M coding rules, tools, and CMS Documentation Guidelines.

You should now have a better understanding, or at least a deeper appreciation, of the complicated steps involved in E/M code selection using the three key components of history, exam, and MDM. But there’s another factor to consider in addition to the formal requirements discussed in this article: medical necessity. If a patient presents with a low-level problem, then the E/M code level should reflect that even if there is extensive documentation that technically meets the requirements for a higher-level E/M code.

The lengthy and often confusing requirements for E/M documentation and coding are a driving force behind the decisions by Medicare and the AMA to revise E/M coding requirements for office and outpatient visit codes in 2021. The new code descriptors for 99201-99215 will emphasize MDM and time, revising the descriptors to require “a medically appropriate history and/or examination.” But remember those changes will focus on a limited number of codes starting Jan. 1, 2021, so understanding the rules of E/M coding using the three key components will remain essential to accurate coding for some time to come.

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