The most often reported codes in the CPT manual are those in the Evaluation and Management (E/M) section. These codes can also be the most troublesome for the new coder to assign because there are so many variables; but once you learn all the intricacies of E/M coding, you will be able to assign E/M codes with complete confidence that you have assigned the correct code. The first step is to review some of the basics of E/M code assignment. If you are comfortable with the basics of E/M code assignment and are familiar with an audit form, go right to Case 1-1 and begin applying E/M codes to physician services.

Within this text, the Centers for Medicare and Medicaid Services (CMS) 1995 Documentation Guidelines (DGs) for Evaluation and Management Services have been referenced when coding E/M services. A copy of the guidelines is located in Appendix C of this text. The discussion that follows about documentation of E/M services has been developed based on these guidelines.

The audit form, located in Appendix A, is only one of many ways a facility could choose to assess the physician’s E/M services provided to the patients of the facility. Third-party payers may have their own documentation requirements and audit forms. As such, they may differ from the information, requirements, and audit form in this text. For the purposes of this text, the audit form that you are going to learn about is how E/M services are to be assessed throughout this text. Let us begin with some basics.

E/M review—the basics

Three factors of E/M code

The codes in the E/M section are based on three factors:

1. Place of service

2. Type of service

3. Patient status

Place of service

The first step in choosing the correct E/M code is to identify the place or setting in which the service was provided. Codes vary based on the place of service. For example, there are different codes for outpatient and inpatient settings.

Type of service

The second step in choosing the correct E/M code is to identify the type of service. The type of service is the kind of service. Examples of types of service are consultation, hospital admission, or an office visit. Codes are divided based on the type of service.

Patient status

The third step in choosing the correct E/M code is to identify the patient status correctly. There are four types of patient status:

1. New patient—has not received professional service from the physician or another physician of the exact same specialty and subspeciality in the same group practice within the past 3 years.

2. Established patient—has received professional service from the physician or another physician of the exact same specialty and subspeciality in the same group practice within the past 3 years.

3. Outpatient—has not been formally admitted to a health care facility.

4. Inpatient—has been formally admitted to a health care facility.

Key components

Once you have identified the place of service, type of service, and patient status, you are ready to locate the information in the medical record that identifies the key components of the service. The three key components are the history, examination, and medical decision-making complexity.

History

The history is the subjective (patient-provided) information that the physician elicits regarding the chief complaint. There are four elements of a history:

 Chief Complaint (CC)

 History of Present Illness (HPI)

 Review of Systems (ROS)

 Past, Family, and Social History (PFSH)

Chief complaint. 

The CC is a concise statement describing the symptom, problem, condition, diagnosis, physician-recommended return, or other factor that is the reason for the encounter/visit, usually in the patient’s words.

All encounters have a CC or reason for the visit. The patient’s medical record will state the CC, most often at the beginning of the report with a title, such as CC, indications, reason for consultation, reason for admission, or similar wording. Sometimes the physician will simply place the CC within the report with no title. For example, in the medical record it stated: “This 6-year-old child is seen in the office today complaining of a sore throat.” Although this is the CC, the statement is not labeled as such.

History of present illness. 

The HPI is a chronological description of the development of the patient’s present illness from the first sign and/or symptom or from the previous encounter to the present. The HPI may include the following:

 Location (site on the body)

 Quality (characteristics, such as throbbing, sharp)

 Severity (how intense or on a scale of 1/10)

 Duration (how long for this problem or episode) (Not listed in CPT as an HPI element)

 Timing (when does it occur)

 Context (under what circumstances does it occur)

 Modifying factors (what makes it better or worse)

 Associated signs and symptoms (what else is happening when it occurs)

The physician documents the HPI in the medical record. The following is an example of an HPI containing each of the elements:

The patient presents with a radiating (quality) pain in the right arm (location). He states that the pain is a 5 on a scale of 1/10 (severity). He states that the pain began last Monday (duration) when he was bending over (context) shoeing his horse in the barn, and he has experienced the same pain several times throughout the week (timing). He tried icing the area on his arm several times, and that did provide him with a bit of relief (modifying factors). There has been some dizziness during these episodes (associated signs and symptoms).

Often the coder has a copy of the encounter report to use when coding services, so the coder can write directly on the copy to identify elements in the report. For example, here is the HPI as it would appear on the coder’s copy of the report, with eight elements of the HPI marked by the coder:

The patient presents with a radiating¹ pain in the right arm². He states that the pain is a 5 on a scale of 1/10³. He states that the pain began last Monday⁴ when he was bending over⁵ shoeing his horse in the barn, and he has experienced the same pain several times throughout the week⁶. He tried icing the area on his arm several times, and that did provide him with a bit of relief⁷. There has been some dizziness during these episodes⁸.

The coder might also use an audit form to check off the information if the facility policy does not allow for an additional copy of the report. The coder must work directly from the original report in these circumstances and place check marks on the audit form rather than on the record. Health care facilities record each report that is accessed or printed due to privacy standards, so never access or print a report for which you are not authorized.

The HPI area of the audit form is illustrated in Figure 1-1.

The extent of the HPI as problem focused, expanded problem focused, detailed, or comprehensive is based on the physician’s professional judgment, depending on the needs of the patient. The two levels of HPI are brief (1–3 elements) and extended (4 or more elements). The problem-focused and expanded problem-focused levels of history contain a brief (1–3) review of the problems surrounding why the patient is being seen that day. The detailed and comprehensive levels of history contain an extended (4 or more) review of the HPI elements. HPI levels are illustrated in Figure 1-2.

Review of systems (ROS). 

The ROS is an inventory of the body systems obtained through a series of questions seeking to identify signs or symptoms that the patient may be experiencing or has experienced. The ROS may be asked by the physician, nurse, or by means of a questionnaire filled out by the patient or ancillary personnel. Regardless of how the information is obtained, before the information can qualify as an ROS, the physician must review the information and document the review in the medical record. The documentation includes both positive responses and pertinent negative responses related to the HPI. The ROS may include the following information or elements:

 Constitutional (e.g., weight loss, fever)

 Ophthalmologic (eyes)

 Otolaryngologic (ears, nose, mouth, throat)

 Cardiovascular

 Respiratory

 Gastrointestinal

 Genitourinary

 Musculoskeletal

 Integumentary (skin and/or breasts)

 Neurological

 Psychiatric

 Endocrine

 Hematologic/Lymphatic

 Allergic/Immunologic

An ROS example from a medical record is as follows:

Review of systems

Eyes: Blurred double vision (ophthalmologic). Ears: Hearing is okay (otolaryngologic). GI: As noted above (gastrointestinal). GU: Negative (genitourinary). Chest: No complaints of dyspnea (respiratory). Neurological: Negative (neurologic). Psychiatric: Negative. Sleep pattern has been off in the past, and he has been treated with amitriptyline. This has not been such a significant problem as of late (psychiatric).

The coder may identify each of these seven ROS elements directly on the copy of the report as follows:

Review of systems

Eyes: Blurred double vision¹. Ears: Hearing is okay². GI: As noted above³. GU: Negative⁴. Chest: No complaints of dyspnea⁵. Neurologic: Negative⁶. Psychiatric: Negative. Sleep pattern has been off in the past, and he has been treated with amitriptyline. This has not been such a significant problem as of late.⁷

If an audit form were used, the ROS area of the audit form would be as illustrated in Figure 1-3.

Since a problem-focused history does not require an ROS, there are only three levels that require an ROS: problem pertinent (expanded problem focused = 1 system), extended (detailed = 2–9 systems), and complete (comprehensive = 10 or more systems). There are times that an ROS is not necessary, such as during a simple recheck of ears. The problem pertinent ROS is a review that is focused on the organ system (OS) involved in the chief complaint, such as a fractured finger in which the musculoskeletal system is the center of the review. The extended ROS includes a review of the system directly involved in the chief complaint, plus related (up to nine) other systems. For example, a complaint of left-sided chest pain would focus primarily on the cardiovascular system but could also include the respiratory system and gastrointestinal system. The complete ROS includes at least 10 of the 14 OSs. The coder counts the number of systems reviewed as documented in the medical record and enters that number on the audit form.

According to Huffman’s Health Information Management,* the following systems are recognized for the ROS:

 Constitutional symptoms

Usual weight, recent weight changes, fever, weakness, fatigue

 Eyes (Ophthalmologic)

Glasses or contact lenses, last eye examination, visual glaucoma, cataracts, eyestrain, pain, diplopia, redness, lacrimation, inflammation, blurring

 Ears, Nose, Mouth, Throat (Otolaryngologic)

Ears: hearing, discharge, tinnitus, dizziness, pain

Nose: head colds, epistaxis, discharges, obstruction, postnasal drip, sinus pain

Mouth and Throat: condition of teeth and gums, last dental examination, soreness, redness, hoarseness, difficulty in swallowing

 Cardiovascular

Chest pain, rheumatic fever, tachycardia, palpitation, high blood pressure, edema, vertigo, faintness, varicose veins, thrombophlebitis

 Respiratory

Chest pain, wheezing, cough, dyspnea, sputum (color and quantity), hemoptysis, asthma, bronchitis, emphysema, pneumonia, tuberculosis, pleurisy, last chest radiograph

 Gastrointestinal

Appetite, thirst, nausea, vomiting, hematemesis, rectal bleeding, change in bowel habits, diarrhea, constipation, indigestion, food intolerance, flatus, hemorrhoids, jaundice

 Genitourinary

 Urinary: frequent or painful urination, nocturia, pyuria, hematuria, incontinence, urinary infection

 Genitoreproductive

Male—venereal disease, sores, discharge from penis, hernias, testicular pain or masses

Female—age at menstruation (frequency, type, duration, dysmenorrhea, menorrhagia; symptoms of menopause), contraception, pregnancies, deliveries, abortions, last Papanicolaou smear

 Musculoskeletal

Joint pain or stiffness, arthritis, gout, backache, muscle pain, cramps, swelling, redness, limitation in motor activity

 Integumentary (skin or breast)

Rashes, eruptions, dryness, cyanosis, jaundice, changes in skin, hair, or nails

 Neurologic (Neurological)

Faintness, blackouts, seizures, paralysis, tingling, tremors, memory loss

 Psychiatric

Personality type, nervousness, mood, insomnia, headache, nightmares, depression

 Endocrine

Thyroid trouble, heat or cold intolerance, excessive sweating, thirst, hunger, or urination

 Hematologic/Lymphatic

Anemia, easy bruising or bleeding, past transfusions

 Allergic/Immunologic

Sneezing, itching eyes, rhinorrhea, nasal obstruction, or recurrent infections

Environmental allergies, such as dust, mold, or latex

^*Definitions from Huffman E: Health Information Management, ed 10. Revised by the American Medical Records Association. Berwyn, IL, Physician’s Record Company, 1994, pp. 57-62.

According to the CPT manual,* the following are the items that indicate a past, family, or social history:

 Past History: A review of the patient’s past experience with illnesses, injuries, and treatments that includes significant information about:

Prior major illnesses and injuries

Prior operations

Prior hospitalizations

Current medications

Allergies (e.g., drug, food)

Age-appropriate immunization status

Age-appropriate feeding/dietary status

 Family History: A review of medical events in the patient’s family that includes significant information about:

The health status or cause of death of parents, siblings, and children

Specific diseases related to problems identified in the CC or HPI and/or ROS

Diseases of family members that may be hereditary or place the patient at risk

 Social History: An age-appropriate review of past and current activities that includes significant information about:

Marital status and/or living arrangements

Current employment

Occupational history

Use of drugs, alcohol, and tobacco

Level of education

Sexual history

Other relevant social factors

Three of the elements of a history (HPI, ROS, and PFSH) are included to varying degrees in all patient encounters. The degree or level of HPI, ROS, and PFSH is determined by the CC or presenting problem of the patient.

*Definitions from 2012 CPT, Evaluation and Management Guidelines, pp. 5-7. CPT codes, descriptions, and materials only are © 2011 American Medical Association.

Not all physicians indicate the OS being reviewed with “Neurological” or “Gastrointestinal,” which makes it necessary for the coder to be able to identify the OS by the terminology used in the report. For example, rather than labeling the section “psychiatric,” the physician may state, “Sleep pattern has been off in the past, and he has been treated with amitriptyline. This has not been such a significant problem of late.” As the coder, you must know that the sleep pattern would be part of a psychiatric ROS.

The ROS area on an audit form is illustrated in Figure 1-4.

The following is an example of the PFSH from a medical record:

Past, family, social history. 

The PFSH is a review of the past, family, and social history of the patient. Some encounters do not include any PFSH elements, whereas other encounters contain an extensive review of all elements. The physician decides the extent of the PFSH based on the needs of the patient. For example, see the following PFSH:

Past medical history

1. Diabetes mellitus

2. Sinusitis

3. Asthma

Medications

1. Humalog 7 units in the morning, noon, and q.h.s.

2. Ultralente 14 units q.a.m. and 14 units q.p.m.

3. Elavil 100 mg p.o. q.h.s.

Family history

Neither of her parents has diabetes mellitus; however, there is a history of diabetes in that her brothers and an uncle all have it. There is also a history of CVAs, myocardial infarctions, and cancer.

Social history

The patient states she consumed alcohol in the past. She smokes three to five cigarettes daily. She is otherwise a normal, healthy high school senior.

The coder would enter each of these elements onto an audit form as documented in the medical record and illustrated in Figure 1-5.

The two levels of PFSH are pertinent (1) and complete (2–3). The problem-focused and expanded problem-focused history do not require any PFSH elements. The detailed history requires one element of the PFSH. For example, if the patient’s CC is an allergic rash, the physician would certainly inquire about the patient’s past history of allergies—drug, food, and inhaled allergies. The complete PFSH includes at least two of the three elements. For example, if the patient had intermittent chest pains, the physician would want to know the family history to identify family members with a history of heart disease and the social history to identify the relevant factors that would contribute to heart disease, such as use of tobacco and diet. The audit form indicates the PFSH as illustrated in Figure 1-6.

There are four levels of history; the level is based on the extent of the history during the history-taking portion of the physician/patient encounter.

History levels

The level is based on the extent of the history. The following are the four levels of history:

1. Problem focused

2. Expanded problem focused

3. Detailed

4. Comprehensive

Problem focused. 

The physician focuses on the CC and a brief history of the present problem of a patient.

 A brief history includes a review of the history regarding pertinent information about the present problem or CC. Brief history information centers on the severity, duration, and symptoms of the problem or complaint. The brief history does not have to include the PFSH or ROS.

Expanded problem focused. 

The physician focuses on a CC, obtains a brief history of the present problem, and also performs a problem-pertinent review of systems. The expanded problem-focused history does not have to include the PFSH.

 This history would center on specific questions regarding the system involved in the presenting problem or CC. The ROS for this history would review the ROS most closely related to the CC or presenting problem. It requires one to three HPI elements, one ROS, and no PSFH. For example, if the presenting problem or CC is a red, swollen knee, the system reviewed would include the musculoskeletal system.

Detailed. 

The physician focuses on a CC and obtains an extended history of the present problem, an extended ROS, and a pertinent PFSH directly related to the patient’s problem.

 The system review is “extended,” which means that it includes a review of the system related to the CC plus additional related systems. The level of history requires at least 4 HPI elements, 2–9 ROS, and at least 1 PFSH element.

Comprehensive. 

This is the most complex of the history types. The physician documents the CC, obtains an extended history of the present problem, does a complete ROS, and obtains a complete PFSH.

 Some third-party payers have established standards for the number of elements that must be documented in the medical record to qualify for a given level of service. For example, a third-party payer may state that to qualify as a comprehensive history, the medical record must document an extended HPI and include four of the eight elements (e.g., location, quality, severity, duration), a complete ROS that included a review of at least 10 of the 14 OSs, and a complete review of all three areas of the PFSH.

The four elements (CC, HPI, ROS, and PFSH) are the basis of the history portion of the E/M service. Figure 1-7 illustrates a completed audit form for a level 3 or detailed history.

To assign a given history level, all three history elements must be at that given level or higher. For example, if the documentation supports an HPI that was extended (at least 4 HPI elements), it would qualify for the comprehensive level history (level 4). If the ROS was extended (2–9 systems), it would qualify for the detailed level history (level 3). If the PFSH was complete (2 or 3 history areas), it would qualify for the comprehensive level history (level 4), this history supports a detailed history (level 3). The history level can be a level 4 only if the HPI was 4 or comprehensive, the ROS was 10+ or comprehensive, and the PFSH was 2 or 3 or comprehensive.

Examination

The history is the subjective information the patient provides the physician, and the examination is the objective information the physician gathers. The examination is the findings that the physician observes during the encounter. The physician documents the examination in the medical record, and the coder uses this documentation to report the service.

The CPT manual recognizes the BAs and OSs listed below with the exception of constitutional. CMS’s 1995 Documentation Guidelines (DG) identify the elements of the examination to include various body areas (BA) and organ systems (OS), as well as an assessment of a patient’s constitutional elements, indicated by such items as the patient’s general appearance, vital signs, or level of distress. The three elements—general (constitutional [OS]), BAs, and OSs—are as follows.

General (constitutional) (OS)

 Blood pressure, sitting*

 Blood pressure, lying*

 Pulse

 Respiration

 Temperature^†

 Height

 Weight

 General appearance

Body areas

 Head (including face)

 Neck

 Chest (including breasts and axillae)

 Abdomen

 Genitalia, groin, buttocks

 Back

 Each extremity

Organ systems

 Ophthalmologic (eyes)

 Otolaryngologic (ears, nose, mouth, throat)

 Cardiovascular

 Respiratory

 Gastrointestinal

 Genitourinary

 Musculoskeletal

 Integumentary (skin)

 Neurologic

 Psychiatric

 Hematologic/Lymphatic/Immunologic

Note: The endocrine system is not listed in either the CPT manual or the 1995 DG as an examination element, although the endocrine system is listed as an OS in the history.

The examination elements may be placed on an audit form. An example of an examination with 4 constitutional, 2 BAs, and 9 OSs is as follows:

Physical examination

The patient is very sluggish,^{(general appearance/constitutional)} although he does answer questions. Blood pressure 96/76,^{(constitutional)} pulse 130, and regular^{(constitutional)} respirations 22.^{(constitutional)} Eyes: Sunken significantly. Fundi are not visualized.^{(OS/ophthalmologic)} Ears: Negative.^{(OS/otolaryngologic)} Carotids are 4/4 without bruits.^{(OS/cardiovascular)} Neck: supple,^(BA/neck) nodes are negative. Thyroid is normal to palpation. Axillary nodes negative.^{(OS/lymphatic)} Chest: Clear to auscultation.^{(OS/respiratory)} Heart: Tachycardic but no extra heart sounds heard. No murmur is appreciated.^{(OS/cardiovascular)} Abdomen: Some minimal tenderness in the right mid abdomen and left upper abdomen.^(BA/abdomen) Genital/Rectal: Not performed. Peripheral extremities reveal good pulses in the legs with no edema.^{(OS/also cardiovascular)} Respiratory: Negative.^{(OS/respiratory)} GI: Negative.^{(OS/gastrointestinal)}

There are 3 OS that are duplicates—cardiovascular has 3 occurrences and respiratory has 2 occurrences. There is only 1 check placed on the audit form for cardiovascular and 1 check for respiratory, even though there are multiple occurrences on the documentation.

One element in the constitutional area equals 1 OS, whether all 8 constitutional elements are checked or only 1 element is checked.

References to extremities that indicate a visual assessment, such as “no clubbing,” “digits intact,” or “arthritic changes,” or references to the abdomen, such as “no masses,” “nontender,” or “soft,” are recorded as a BA. References to extremity pulses, such as “pedal” or “peripheral,” are recorded as the cardiovascular system. If there is more than 1 part of the BA or OS checked in the BA/OS area (such as otolaryngologic, ears, nose, mouth, throat), there is still only 1 check placed on that line on the audit form. For example, the documentation indicates that the ears, nose, and mouth are examined. Only 1 check is placed on the “Otolaryngologic” line on the audit form. An exception to this is the extremities, in which case when all the extremities are referenced, 4 checks are placed on the extremity line on the form (unless a specific number of extremities is specified).

Figure 1-8 illustrates the audit form with examination elements recorded.

The reports in the medical record are transcribed in a variety of locations by many transcriptionists. Although most facilities have an established report format, not all facilities have the same report format, and even if they have a format, not every physician or transcriptionist follows the format completely. As such, you need to be able to work with a variety of report formats, and you will not like all of them equally. For example, you will learn to appreciate a report in which the examination elements are in capital letters, but remember that format is no substitution for reading the entire report. Within this text, you will see an assortment of report formats that represent real-world medical reports.

The following are the four levels of examination based on the extent of the examination:

1. Problem focused: Examination is limited to the affected BA or OS identified by the CC. It involves 1 OS or BA.

2. Expanded problem focused: A limited examination of the affected BA or OS and other related BAs or OSs. It involves a limited examination of 2–7 BAs or OSs.

3. Detailed: An extended examination of the affected BAs or related OSs. It involves an extended examination of 2–7 BAs or OSs.

4. Comprehensive: This is the most extensive examination; it encompasses at least 8 OSs. For the purposes of this text, body areas will be counted for a comprehensive examination, although many coders only count organ systems.

The elements required for each level of examination are illustrated in Figure 1-9.

The levels of examination include both body areas (BA) and organ systems (OS), with the exception of the comprehensive examination. The comprehensive examination requires a minimum of 8 OSs without counting body areas. When abstracting a medical record, count both the BA and OS. If the level of the examination rises to a comprehensive level, recount, and this time only count the OSs. If there are at least 8 OSs, the examination remains at a comprehensive level. If, upon recount, there are not 8 OSs in the examination, the examination does not qualify as a comprehensive level examination. For example, a medical report indicated 12 BAs/OSs, of which 7 were BAs and 5 OSs. If you counted both BAs and OSs, the examination would be a comprehensive level examination; but following the rule regarding counting only OSs for the comprehensive level, the examination included only 5 OSs and would not qualify as comprehensive. There are many coders who interpret the comprehensive level in the 1995 DG as allowing the counting of BA, and if that method is consistent across all services to all patients in the practice, the method is not incorrect. For this text, the approach is to not count BA for a comprehensive level examination. Also remember that constitutional on the examination counts as 1 OS and that OS counts when calculating the examination. For example, there was 1 element of the constitutional (1 OS), 5 BAs, and 7 OSs indicated in the report for a total of 14 BAs/OSs, which would ordinarily be a comprehensive examination. Recounting without including the BAs, there are 1 constitutional (1 OS) and 7 OSs for a total of 8 OSs, which is still a comprehensive examination.

Within this text, when a comprehensive examination is being reported and the recount excludes the BAs from the count, the OSs will be listed after the total BAs/OSs. For example, if there were 14 BAs/OSs identified in the examination and a recount determined that only 7 of the 14 were OSs, this would be displayed on the audit form as “14 (7)”, indicating there were only 7 OSs. See Figure 1-10 for an example.

The expanded and detailed examinations contain 2 to 7 BAs or OSs. The difference is that the expanded problem focused examination is limited and is focused on the BA/OS of the CC and other directly related BAs/OSs, whereas the detailed examination is more expansive and covers not only the BAs/OSs of the CC but also other BAs/OSs not directly related to the CC.

Medical Decision Making Complexity

The key component of MDM is based on the complexity of the decision the physician must make regarding the patient’s diagnosis and care. Complexity of decision making is based on three elements:

1. Number of diagnoses or management options. The options can be minimal, limited, multiple, or extensive.

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2. Amount and/or complexity of data to review. The data can be minimal or none, limited, moderate, or extensive.

3. Risk of complication and/or death if the condition goes untreated. Risk can be minimal, low, moderate, or high.

Although the level of the MDM is the most subjective element in establishing the level of E/M services, characteristics of the MDM can indicate complexity. The information that follows will provide you with foundational information regarding the MDM.

Number of diagnoses or management options. 

Some basic guidelines for documentation of management options in the medical record are as follows:

1. For each encounter, an assessment, clinical impression, or diagnosis should be documented. It may be explicitly stated or implied in documented decisions regarding management plans or further evaluation.

 For a presenting problem with an established diagnosis, the record should reflect whether the problem is (a) improved, well controlled, resolving, or resolved; or (b) inadequately controlled, worsening, or failing to respond as expected.

 For a presenting problem without an established diagnosis, the assessment or clinical impression may be stated in the form of differential diagnoses or as a “possible,” “probable,” or “rule out” (R/O) diagnosis.

2. The initiation of, or changes in, treatment should be documented. Treatment includes a wide range of management options, including patient instructions, nursing instructions, therapies, and medications.

3. If referrals are made, consultations requested, or advice sought, the record should indicate to whom or where the referral or consultation is made or from whom the advice is requested.

Data to be reviewed. 

The following are some basic documentation guidelines for the amount and complexity of data to be reviewed:

1. If a diagnostic service (test or procedure) is ordered, planned, scheduled, or performed at the time of the E/M encounter, the type of service (e.g., laboratory or radiology) should be documented.

2. The review of laboratory, radiology, or other diagnostic tests should be documented. An entry in a progress note such as “WBC elevated” or “chest x-ray unremarkable” is acceptable. Alternatively, the review may be documented by initializing and dating the report containing the test results.

3. A decision to obtain old records or to obtain additional history from the family, caregiver, or other source to supplement that obtained from the patient should be documented.

4. Relevant findings from the review of old records or the receipt of additional history from the family, caregiver, or other source should be documented. If there is no relevant information beyond that already obtained, that fact should be documented. A notation of “old records reviewed” or “additional history obtained from family” without elaboration is insufficient.

5. The results of discussion of laboratory, radiology, or other diagnostic tests with the physician who performed or interpreted the study should be documented.

6. The direct visualization and independent interpretation of an image, tracing, or specimen previously interpreted by another physician should be documented.

Risk. 

Some basic documentation guidelines for risk of significant complications, morbidity, or mortality include the following:

1. Comorbidities, underlying diseases, or other factors that increase the complexity of MDM by increasing the risk of complications, morbidity, or mortality should be documented.

2. If a surgical or invasive diagnostic procedure is ordered, planned, or scheduled at the time of the E/M encounter, the type of procedure (e.g., laparoscopy) should be documented.

3. If a surgical or invasive diagnostic procedure is performed at the time of the E/M encounter, the specific procedure should be documented.

4. The referral for or decision to perform a surgical or invasive diagnostic procedure on an urgent basis should be documented or implied.

Examples of the levels of risk are found in Table 1-1.

TABLE 1–1

EXAMPLES OF LEVELS OF RISK

Levels of Risk	Presenting Problem or Problems
Minimal (Level 1)	One self-limited or minor problem (e.g., insect bite, tinea corporis)
Low	Two or more self-limited or minor problems
(Level 2)	One stable, chronic illness (e.g., well-controlled hypertension or non–insulin-dependent diabetes, cataract, benign prostatic hypertrophy) Acute, uncomplicated illness or injury (e.g., cystitis, allergic rhinitis, simple sprain)
Moderate (Level 3)	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)
High (Level 4)	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 body function (e.g., multiple trauma, acute myocardial infarction, 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 (e.g., seizure, transient ischemic attack, weakness, or sensory loss)

The extent to which each of these elements is considered determines the levels of MDM complexity:

1. Straightforward: Minimal diagnosis and/or management options, minimal or none for the amount and complexity of data to be reviewed, and minimal risk to the patient of complications or death if untreated.

2. Low complexity: Limited number of diagnoses and/or management options, limited data to be reviewed, and low risk to the patient of complications or death if untreated.

3. Moderate complexity: Multiple diagnoses and/or management options, moderate amount and complexity of data to be reviewed, and moderate risk to the patient of complications or death if untreated.

4. High complexity: Extensive diagnoses and/or management options, extensive amount and complexity of data to be reviewed, and high risk to the patient for complications or death if the problem is untreated.

When you select one of the four types of MDM complexity—straightforward, low, moderate, or high—the documentation in the medical record must support the selection in terms of the number of diagnoses or management options, amount or complexity of data to be reviewed, and risks.

Given the information in the medical record, you would consider the information in the context of the complexity of the diagnosis and management options, data to be reviewed, and risks to the patient to choose the complexity of MDM. The MDM portion of an audit report would be as illustrated in Figure 1-11. To qualify for a given level of MDM complexity, two or three elements must be met or exceeded. This differs from the history where all three elements must be of the same or greater level.

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