The Three Key Components History, Exam and Medical Decision-Making by mrsafety987

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									The Three Key Components: History, Exam and Medical Decision-Making
By Erica Schwalm

Evaluation & Management codes are divided based on several factors. Location and patient status (e.g. inpatient, outpatient, office
visit, ER visit, observation, new patient, established patient, etc.) and, in some cases, patient age (e.g. inpatient critical care services).
That’s the easy part! Many of the categories/subcategories of E/M codes are further divided into “levels” of service based on the
intensity of the service. This is the tricky part. How do you measure the intensity of a service? The patient, the condition(s),
underlying conditions and countless other things can affect how intense a service will be. Auditors, consultants and physicians alike
agree that reporting the appropriate level of service is not an exact science and that certain gray areas do still exist. However, there
are areas of the E/M guidelines that are quite clear, specifically when it comes to the three key components, which will be discussed
in detail.

Providers are responsible for assigning the appropriate level of service, therefore are expected to understand the E/M documentation
guidelines. Misunderstanding the guidelines leads to noncompliant habits such as “undercoding”, “overcoding”, reporting for
reimbursement rather than medical necessity or consistently billing the same level of service. Whether intentional or not, consistent
noncompliant practices is a serious act – ignorance is not a defense against fraud.

The first step is to understand the E&M documentation guidelines. In most cases, the three key components – history, examination,
and medical decision making – are the primary components in selecting a level of service. Each of the three key components must be
thoroughly understood:

There are four types/extents of history:

     •   PF - Problem focused (CC, brief HPI)
     •   EPF - Expanded problem focused (CC, brief HPI, pertinent ROS)
     •   D - Detailed (CC, extended HPI, extended ROS, pertinent PFSH)
     •   C - Comprehensive (CC, extended HPI, complete ROS, complete PFSH)

To determine the correct type/extent of history, you must understand the four elements of history: CC, HPI, ROS, and PFSH, which are described
in detail below.

* CC (Chief Complaint)
The CC, defined as "a concise statement describing the symptom, problem, condition, diagnosis or other factors, usually stated in the patient's
words" is required at all history levels and must be clearly documented.

* HPI (History of Present Illness)
HPI is defined as a chronological description of the development of the patient's present illness from the first sign/symptom to the present.

There are two levels of HPI-brief and extended. A brief HPI consists of 1 - 3 of the following elements; an extended HPI consists of 4 - 8 of
the following elements:

        Location - where problem, pain or symptom occurs, e.g. specific body area, diffuse or localized, unilateral or bilateral, etc.
        Duration - how long problem, pain or symptom has persisted, e.g. since last week, for 5 years, etc.
        Severity - description of severity of problem, pain or symptom, e.g. 1 - 10 rating, mild moderate, severe or may be assessed by
         nonverbal signs of discomforts.
        Quality - description of problem, symptom or pain, e.g. dull, aching, stabbing, burning, constant, chronic, acute, intermittent, stable,
         improving, worsening.
        Timing - when the problem, pain or symptom occurs, e.g. worse in the morning or at night, continuous, etc.
        Modifying factors - actions taken to make the problem, symptom or pain better of worse, e.g. pain relievers help with pain,
         bending makes pain worse, etc.
        Context - instances that can be associated with the problem, pain or symptom, e.g. while standing for a long time, when standing, etc.
        Association signs and/or symptoms - Other problems that occur with primary problem, symptom or pain, e.g. stress causes

* ROS (Review of Systems)
The ROS is defined as "an inventory of body systems obtained through a series of questions seeking to identify signs and/or symptoms
which the patient may be experiencing or has experienced."

There are three levels of ROS - problem pertinent, extended and complete. Problem pertinent requires documentation of one of the recognized
systems, extended requires 2 - 9 of the systems and a complete ROS requires documentation of 10 or more systems.
The following systems are recognized:
     • Constitutional symptoms (e.g., fever, weight gain or loss, fatigue, weakness, etc)
     • Eyes (e.g., double vision, blurred vision, etc.)
     • Ears, Nose, Mouth, Throat (e.g., difficulty swallowing, sinuses, etc.)
     • Cardiovascular (e.g., chest pain)
     • Respiratory (e.g., SOB)
     • Gastrointestinal (e.g., stomach pain, heartburn, bowel movements)
     • Genitourinary (e.g., dysuria, burning, frequency, etc.)
     • Musculoskeletal (e.g., pain, stiffness, pain ,swelling, etc.)
     • Integumentary (e.g., rashes, pain, lumps)
     • Neurologic (e.g., seizures, fainting, headaches, numbness, etc.)
     • Psychiatric (e.g., sleeping habits, feelings, etc.)
     • Endocrine (e.g., thyroid problems, excessive thirst or sweating, etc.)
     • Allergic/immunologic (e.g., allergies, reactions, immune symptoms of problems)

* (PFSH) Past, Family and Social History
Past History - a review of prior illnesses, injuries, operations, hospitalizations, medications, etc.
Family History - a review of medical events in the patient's family that are hereditary or place the patient at risk.
Social History - review of habits such as smoking or drug use, living arrangements, occupation, etc.

There are two levels of PFSH - pertinent and complete. Pertinent requires that one specific item from any of the three history areas be
documented. A complete PFSH is one specific item from all three areas for new patients and consults. Only two history areas are required for
established patients.

** When documenting a complete ROS, document all positive and pertinent negative responses. A phrase such as "all other systems negative" is
acceptable if the physician reviewed all systems.

**The ROS/PFSH may be recorded on a form by a staff member or by the patient. To document the physician reviewed the information, there
must be notation supplementing or confirming the information recorded by others and the location of the form must be referred to in the chart.

** A ROS/PFSH recorded at an earlier encounter does not need to be rerecorded as long as there is evidence the physician reviewed and updated
the previous information. This may be documented by describing any new ROS/PFSH information or noting any changes/no changes AND
noting the date and location of the earlier ROS/PFSH.

Use this chart to determine the type of history based on the extent of HPI, ROS and PFSH. Note: CC (chief complaint) is required at all levels.
To qualify for a given type of history all elements in the table must be met:

Type of History                     CC                HPI               ROS                      PFSH

PF - Problem focused                Required          Brief (1-3)       N/A                      N/A

EPF - Expanded problem focused      Required          Brief (1 -3)      Problem Pertinent (1)    N/A

D - Detailed                        Required          Extended (4+)     Extended (2 - 9)         Pertinent (1 Hx area)

C - Comprehensive                   Required          Extended (4+)     Complete (10+)           Complete (3 new pt., 2 est. pt)

2. Exam (1995 Guidelines):
The next key component is the examination. Like history, there are four exam types - PF, EPF, D, C - To determine the extent of
examination performed, see the descriptions below.

Type of Exam                           Performed and Documented:

PF                                     Limited exam of one body area or organ system
                                       1 body area or organ system
EPF                                 Limited exam of affected body area/organ system + any other symptomatic or related body
                                    area/organ system.
                                    2 - 7 body areas and/or organ systems
                                    (Or 2 – 4 depending on auditor)

D                                   Extended exam of the affected body area(s)/organ system(s) + other symptomatic or related body
                                    areas/organ systems
                                    2 - 7 body areas and/or organ systems with at least 1 in detail
                                    (Or 5 – 7 depending on auditor)

C                                   General multisystem examination
                                    8 or more findings about the organ systems and/or body areas

Organ systems and body areas according to the 1995 CMS guidelines:

•   Constitutional (Vitals and general appearance of patient e.g., development, nutrition, body habitus, deformities, attention to
•   Eyes (Inspection of conjunctivae and lids; exam of pupils and irises)
•   Ears, nose, mouth and throat
•   Cardiovascular (exam of peripheral vascular system by observations and palpation, e.g. swelling, varicosities, pulses,
     temperature, edema, tenderness)
•   Respiratory (assessment of respiratory efforts, percussion and palpation of chest, auscultation of lungs)
•   Gastrointestinal (examination of abdomen)
•   Musculoskeletal
•   Skin (inspection and/or palpation of skin and subcutaneous tissue)
•   Neurological (coordination, deep tendon reflexes and/or nerve stretch test with notation of pathological reflexes and examination
     of sensation)
•   Psychiatric (mood and affect; orientation to time place and person)
•   Lymphatic (palpation of lymph nodes)

Body areas:
• Head/face
• Neck
• Chest
• Abdomen
• Genitalia, groin, buttocks
• Back, including spine
• Each extremity

** Don't count both the body area and the organ system. For example if you are counting the spine and two extremities for body areas,
you cannot also get separate credit for the musculoskeletal system.

CMS Documentation guidelines:

1. Specific abnormal and relevant negative findings of the exam of the affected or symptomatic areas/systems should be
   documented. A notation of "abnormal" without elaboration is insufficient.
2. Abnormal or unexpected findings on the examination of any asymptomatic area/system should be described.
3. A brief statement or notation indicating "negative" or "normal" is sufficient to document normal findings related to unaffected areas or

3. Medical Decision Making (MDM)
The last key component is medical decision making, which is composed of the presenting problem, amount and/or complexity of data to
be reviewed, and risk.
There are four types of MDM:
• Straightforward
• Low complexity
• Moderate complexity
• High complexity

The first element is the Number of diagnosis and management options, which is calculated using a point system. The more complex the
problem, the more points are given. Use the following chart to determine how many points will be given.

 1.    Number of Diagnosis & Management Options:
Category of Problem(s)            Occurrence of       Value       TOTAL
                                  P ruble m(s)
                                  (max 2)         X   1       =
Self-limited or minor problem
Established problem, stable or                    X   1       =
Established problem, worsening                    X   2       =

New problem, no additional        (max 1)         X   3       =
workup planned
New problem, additional workup                    X   4       =

Next is Amount and/or Complexity of Data Reviewed, which is also based on a point system. Use the following chart to determine points
for this element.

 2. Amount and/or Complexity of Data Reviewed:
Data Type:                                                           Points

Lab(s) ordered and/or reviewed                                       1

X-ray(s) ordered anchor reviewed                                     1
Medicine section (90701 - 99199)ordered and/or reviewed (ex. PT,
EMG, psych)
Discussion of test results with performing physician                  1
Decision to obtain old records and/ or obtain history from some one   1
other than the patient
Review and summary of old records and/or discussion with other health 2
Independent visualization of images, tracing or specimen.             2


Last step is determining the level of risk. There are four levels of risk:
• Minimal
• Low
• Moderate
• High

Use the chart on the next page to determine if the overall risk is minimal, low, moderate or high based on the presenting problem, tests
ordered and management options selected.

**The highest one in any one category determines the overall risk. For example, if the presenting problem and tests ordered both
fall into the low category but the management options fall into the moderate category, the overall risk for the encounter would be

 3.     TABLE OF RISK (The highest one in any one category determines the overall Risk)
Level of      Presenting Problem(s)                             Diagnostic Procedure(s) Ordered                  Management Option(s) Selected

Minimal                                                         * Lab tests requiring venipuncture
              * One self-limited or minor problem,                                                               * Rest
                                                                * Chest x-rays
              e.g., cold, insect bile, tinea corporis           * EKG/EEG                                        * Gargles
                                                                * Urinalysis                                     * Elastic bandages
                                                                * Ultrasound
                                                                                                                 * Superficial dressings
                                                                 * KOH prep

Low           *Two or more self-limited or minor problems       *Physiologic tests not under stress, e.g. PFTs   * Over-the-counter drugs
              * One stable chronic illness, e.g. well           *Non-cardiovascular imaging studies w/           * Minor surgery w/ no identified risk
              controlled HTN, NIDDM, cataract, BPH              contrast, e.g. barium enema                      factors
              * Acute, uncomplicated illness or injury, e.g.,   * Superficial needle biopsies                    * PT/OT
              allergic rhinitis or simple sprain, cystitis      * Lab tests requiring arterial puncture          * IV fluids w/o additives
                                                                * Skin biopsies

                                                                                                                 * Minor surgery with identified
              * One or more chronic illnesses with              * Physiologic tests under stress, e.g.           risk factors
Moderate      mild exacerbation, progression or side            cardiac stress test, fetal contraction           * Elective major surgery (open,
              effects of treatment                              stress tests                                     percutaneous, or endoscopic) with
              * Two or more stable chronic illnesses            * Diagnostic endoscopies w/ no                   no identified risk factors
              * Undiagnosed new problem with                    identified risk factors                          *Prescription drug management
              uncertain prognosis, e.g. lump in                 * Deep needle or incisional biopsies             *Therapeutic nuclear medicine IV
              breast                                            * Cardiovascular imaging studies                 fluids with additives
              * Acute illness with systemic                     with contrast and no identified risk             * Closed Tx of Fx or
              symptoms, e.g. pyelonephritis, colitis.           factors e.g. arteriogram, cardiac cath           dislocation w/o manipulation
              * Acute complicated injury, e.g. head             * Obtain fluid from body cavity, e.g.
              injury with brief loss of consciousness           lumbar puncture, thoracentesis,

              * One or more chronic illness with                * Cardiovascular imaging studies with            * Elective major surgery with
High          severe exacerbation, progression, or              contrast with identified risk factors            identified risk factors
              side effects of treatment                         * Cardiac electrophysiological tests             * Emergency major
              * Acute or chronic illnesses or injuries          * Diagnostic endoscopies with                    surgery
              that pose a threat to life or bodily              identified risk factors                          * Parenteral controlled
              function, e.g. multiple trauma, acute             * Discography                                    substances
              MI, severe respiratory distress,                                                                   * Drug therapy requiring intensive
              progressive severe rheumatoid                                                                      monitoring for toxicity
              arthritis, psychiatric illness with                                                                * Decision not to resuscitate or to
              potential threat to self or others.                                                                de-escalate care because of poor
              * An abrupt change in neurological                                                                 prognosis.
              status, e.g. seizure, TIA, weakness,
              sensory loss.

 Use the chart below to determine the overall medical decision making by bringing the information down from the other three
 charts. The overall MDM is determined by the highest 2 out of the 3 categories.

 For example: You scored 3 points for diagnosis and management options, 2 points for data reviewed and the level of risk was
 moderate. In this scenario, the overall MDM is moderate.

Overall Complexity of Medical             1. Number of                        2. Amount and Complexity of Data 3. Risk
Decision Making                           Diagnosis/Management                to be reviewed
Straightforward                           0- 1                                0-1                                    Minimal

Low                                       2                                   2                                      Low

Moderate                                  3                                   3                                      Moderate

                                          4+                                  4+                                     High
 (Overall MDM is determined by the highest 2 out of the 3 above categories)

        Identify chief complaint
        Count the number of HPI elements
        Count the number of ROS
        Count the number of PFSH
           Determine extent of history
        Count the number of body areas and organ systems
           Determine the extent of examination
        Count the points for number of diagnosis and management
        Count the points for amount and complexity of data reviewed
        Determine level of risk
           Determine overall complexity of medical decision making

The next step is to determine the correct level of service.
** New patient visits and consultations require that all three of the key components are met.
** Established patient visits only require two of the three key components.


- New patient office visit with a comprehensive history, comprehensive examination and medical decision making of moderate
complexity. 99204

- New patient visit with comprehensive history, detailed exam and medical decision making of moderate complexity. 99203

- Established patient office visit with a detailed history, detailed exam and low MDM. 99214

- Established patient office visit with a comprehensive history, expanded problem focused exam, and straightforward medical
decision making. 99213

See the charts on the next page for requirements of some levels of service and average times.

** Remember: Time is the least significant factor in determining the level of service

The exception to this is in the case where counseling and/or coordination of care dominates the encounter (face-to-face time in the office
setting). If more that 50% of the encounter is spent on counseling/coordination of care, then time is considered the controlling factor.

If the physician elects to report the level of service based on counseling and/or coordination of care, the total length of time of the
encounter should be documented and the record should describe the amount of time and nature of the counseling and/or activities to
coordinate care.

PF – problem focused
EPF – expanded problem focused
D – detailed
C – comprehensive
MDM – medical decision making
SF – straightforward

Established Patient Office Visits (2/3)
Level of Service   History      Exam      MDM        Avg. time (minutes)

99211              N/A          N/A       N/A        5
99212              PF           PF        SF         10
99213              EPF          EPF       Low        15
99214              D            D         Moderate   25
99215              C            C         High       40

New Patient /Office Consultations (3/3)
Level of Service   History      Exam      MDM        Avg. time (minutes)

99201/99241        PF           PF        SF         10/15
99202/ 99242       EPF          EPF       SF         20/30
99203/ 99243       D            D         Low        30/40
99204/ 99244       C            C         Moderate   45/60
99205/ 99245       C            C         High       60/80

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