How Do You Use History, Exam, and Medical Decision Making in E/M Coding?

In E/M coding, history, examination, and medical decision making (MDM) are the three key components, which means they are major factors in determining which level of E/M code you should report. But selecting the correct type of history, exam, and MDM can feel intimidating even for seasoned coders. Let’s take some of the mystery out of these key components to help ensure cleaner coding and accurate reimbursement for E/M codes.

Basic Steps to Select an E/M Code

The following is an example of how a provider selects an E/M code. Different encounters may require different steps (for instance, you can read about using time as the defining element in What Are E/M Codes?). But this scenario provides a general idea that applies to many E/M codes.

Suppose a cardiologist sees a new patient for an office visit in an outpatient clinic setting. To report the rendered service, the cardiologist must select E/M code category 99201-99215 (Office or other outpatient visit for the evaluation and management of a new patient …), and then select the appropriate level of E/M service from one of the category’s five levels.

To determine the appropriate E/M code, the provider must make a judgment regarding the patient’s condition for each key component — patient history, examination, and medical decision making (MDM). Then, the provider must make more judgments about the nature and extent of work provided.

The E/M coding processes include determining the service levels through several steps:

1. Determine the level of history. History encompasses reviewing the history of the present illness; the appropriate organ systems; and past medical, family and social history; and assessing an array of physiological factors within each of the areas of history and up to 14 organ systems.

2. Determine the level of the physical exam. For the required multiorgan system examination, the provider uses clinical judgment relative to the nature of the patient’s problem(s) to determine the extent of the examination for each organ system. After the provider conducts the exam, he must decide whether the exam is problem focused, expanded problem focused, detailed, or comprehensive.

3. Determine the level of medical decision making (MDM). MDM is how the provider rates the degree of difficulty in establishing a patient’s diagnosis and treatment plan. The E/M service levels recognize four types of MDM — straightforward, low complexity, moderate complexity, and high complexity. Identifying the appropriate type requires another three layers of decisions. CPT® guidelines state MDM is based on two out of the following three elements:

a. The number of diagnoses or care options (minimal, limited, multiple, or extensive);

b. The amount and/or complexity of data to be reviewed (minimal/none, limited, moderate, or extensive); and

c. The risk of complications and/or morbidity/mortality (minimal, low, moderate, or high).

For the final element above, you can use the Table of Risk in the CMS 1995 Documentation Guidelines and 1997 Documentation Guidelines for E/M to help determine the correct level.

Once you’ve determined the levels for history, exam, and MDM, you can select your E/M code. If, for example, the cardiologist performs a comprehensive history, a comprehensive exam, and medical decision making of high complexity for this new patient, then the appropriate code would be 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: 4 Types

Let’s start with the history component. There are four types of history in E/M coding:

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

You should consider four elements when determining the type of history: chief complaint; history of present illness; system review; 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. All history types require a chief complaint.

The other elements require more explanation, as you’ll discover below.

E/M History Component: History of Present Illness

A history of present illness (HPI) is a description of the patient’s current illness. HPI covers development of the illness from the first sign or symptom to the current time.

  • The CPT® E/M guidelines list 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 the list above.
  • According to CPT® E/M guidelines, HPI may be brief or extended. The CMS 1995 and 1997 Documentation Guidelines help define these terms.
    • 1995: A brief HPI describes one to three elements (like location, quality, severity). An extended HPI consists of four or more elements.
    • 1997: 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, see Extended History Status and Chronic Conditions in E/M Coding below.

E/M History Component: Review of Systems

System review, or review of systems (ROS), is an inventory of body systems to identify past and present signs and symptoms. A series of questions helps to define the problem, clarify the differential diagnosis, identify testing that may benefit the patient, and provide baseline data about other body systems that relate to treatment options. The body systems listed by both the CPT® guidelines and CMS 1995 and 1997 Documentation Guidelines are the same and are in the list below.

  • 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 (problem pertinent plus a limited number of other systems), 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.
  • 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 or pertinent negative responses. For the other systems, Medicare allows a note of “all other systems are negative.”

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

Past, family, and/or social history (PFSH) is a review of three possible areas:

  • Past history is a review of the patient’s previous illnesses, injuries, and treatments such as prior major illnesses and injuries, operations, and hospitalizations; current medications; 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 immediate family (parents, siblings, children); diseases that relate to the chief complaint, history of present illness, or system review; hereditary diseases; and diseases of family members that could 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.

PFSH may be pertinent or complete.

Pertinent PFSH is a review of areas related to the problems noted in the HPI. So one item from any of the three areas will qualify as pertinent PFSH, according to 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.

E/M categories that require only an interval history (subsequent hospital care, follow-up inpatient consults, and subsequent nursing facility care) don’t require PFSH.

E/M History Component: Determine the Type of History

Once you’ve determined the level of HPI, ROS, and PFSH, you can use Table 2, taken from Medicare’s Evaluation and Management Services booklet, to select the correct type of history for your E/M code

Table 1: Elements Required for Each Type of History for E/M

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 History Status and Chronic Conditions

We mentioned earlier that 1995 Documentation Guidelines require the medical record to include four or more elements of the 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. The provider should indicate the status of these conditions and any information about them pertinent to the visit. Because of this rule difference, the 1997 Documentation Guidelines might result in coding a higher-level E/M service for encounters that involve, for instance, periodic prescription renewals.

Let’s look at an example. Suppose a Medicare patient who has controlled benign hypertension (I10, Essential (primary) hypertension), controlled type 2 diabetes (E11.9, Type 2 diabetes mellitus without complications), and elevated cholesterol and triglycerides (E78.2, Mixed hyperlipidemia) 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 rosuvastatin 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. When combined with a chief complaint, an appropriate extended ROS and pertinent PFSH, the extended HPI can result in a detailed history.

If the provider performs either a detailed examination or moderate-complexity medical decision making, report the encounter with 99214, assuming medical necessity supports reporting that code.

E/M Exam Component: Body Areas and Organ Systems

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 both use these terms, 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 guidelines.

Before we get to the levels, it’s helpful to know the body areas and organ systems involved. First are the lists referenced by CPT® and the 1995 E/M Documentation Guidelines for exams.

Body areas:

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

Organ systems:

  • Eyes
  • Ears, nose, mouth, and throat
  • Cardiovascular
  • Respiratory
  • Gastrointestinal
  • Genitourinary
  • Musculoskeletal
  • Skin
  • Neurologic
  • Psychiatric
  • Hematologic/lymphatic/immunologic
  • The 1995 Documentation Guidelines add “Constitutional (e.g., vital signs, general appearance)

The 1997 Documentation Guidelines state instead that the exams are defined for general multi-system exams and the single organ systems listed below.

  • 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 Documentation Guidelines take the definitions for examination from the CPT® E/M guidelines and then expand on them. Below you’ll find an overview, but the information for the 1997 Documentation Guidelines applies to multi-system exams only. The 1997 Documentation Guidelines also provide 25 pages of specific requirements for single organ system exams, so check for those details in the guidelines.

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

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

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 Documentation Guidelines.

The 1997 Documentation Guidelines state that this level 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 Documentation Guidelines. The similarity between the 1995 detailed and expanded problem focused exams has caused confusion for coders.

The 1997 Documentation Guidelines state this exam level consists of performing and documenting 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 Documentation Guidelines state. The guidelines neglect, however, to specifically define what constitutes a single-system comprehensive exam.

The 1997 Documentation Guidelines indicate that this level of 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, “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.” See Table 2 for bullets.

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 MDM Type

One of the most complicated and misunderstood areas of E/M level of service calculation is the MDM portion of an encounter. The key is to focus individually on each of the three MDM elements that your provider performs:

  • Number of diagnoses and/or the number of management options
  • Complexity of medical records, diagnostic tests, and/or other data
  • Risk of complications, morbidity, comorbidities, and/or mortality, associated with the patient’s presenting problem(s), the diagnostic procedure(s), and/or the possible management options.

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

Table 3: Elements Required for Each Level of MDM in E/M Coding

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 score at a particular level to assign that level of MDM. For example, if the number of diagnoses is minimal, but the amount and complexity of data and level of risk are both moderate, your MDM score is moderate. An alternative method to determine the correct level of MDM is to eliminate the highest and lowest scores, and the remaining score is the level for the particular MDM in question.

Even the 1995 and 1997 Documentation Guidelines don’t provide specifics on how to reach each level, so many practices and payers use a tool like the Marshfield point system to make the process clearer. But when you’re using point tools like that, remember to compare them to your payer’s rules and rely most heavily on official guidelines rather than unofficial (but often useful!) recommendations.

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

Start your MDM level assessment by tackling the first category: number of diagnoses. For this category, ask, “What is wrong with the patient?” and “What is the total number of medical diagnoses that the patient has that the provider addressed during the encounter?”

The 1995 and 1997 Documentation Guidelines offer advice about which conditions typically involve simpler decision making, like diagnosed problems and ones that are improving.

The Marshfield tool tried to quantify this using the point system below.

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

Then you translate the points to levels.

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

E/M MDM Component: Data Complexity

The second component to consider when deciding on your provider’s MDM complexity is the amount and complexity of the encounter’s data. The 1995 and 1997 Documentation Guidelines indicate that deciding to review old medical records and the types of diagnostic tests ordered and how they’re reviewed can indicate the level of complexity.

Your point tool is likely to look something like the list below.

  • 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 up the points.

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

E/M MDM Component: Risk

The final of the three MDM categories, level of risk, can be the most difficult part to determine. Level of risk involves three subcategories: presenting problem, diagnostic procedures ordered, and management options.

The highest score from only 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 state “the determination of risk is complex and not readily quantifiable.” But to help, the 1995 and 1997 Documentation Guidelines both include a Table of Risk (see Table 4) with common clinical examples.

Table 4: MDM Table of Risk for E/M Coding

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

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