Internal Medicine Coding Alert

Question: We have enough details for an encounter to reach these levels:

• HPI – detailed
• ROS – complete
• PFSH – complete
• EXAM – 10 systems
• MDM – moderate.

Is this documentation sufficient to support a Level 5 E/M code for an established patient?

Tennessee Subscriber

Answer: First, realize there is no such level of HPI (history of present illness) classified as “detailed.” If you have 1-3 HPI elements, the HPI is classified as “brief;” more than 3 elements (or the status of at least 3 chronic or inactive conditions under the 1997 guidelines) is considered “extended.”

For the sake of answering your question, we’ll assume a brief HPI (1-3 elements). That plus a complete ROS and PFSH would support a level of history that is expanded problem focused (because an extended HPI is required for a detailed or comprehensive history). The exam appears comprehensive, and medical decision making (MDM), as noted, is moderate.

The code for a Level 5 established patient visit is 99215, which requires 2 of the following 3 key components:

•  A comprehensive history
• A comprehensive exam
• Medical decision making of high complexity.

Since you seem to have only one of those components, you cannot report a 99215 for the service. That leads you to 99214 (Office or other outpatient visit for the evaluation and management of an established patient, which requires at least 2 of these 3 key components: A detailed history; A detailed examination; Medical decision making of moderate complexity). Since you meet or exceed two of those three components (i.e. you have a comprehensive exam and medical decision making of moderate complexity), you could report 99214 for the encounter based on the exam and medical decision making.

Key: As always, medical necessity should be considered, and the amount of history and exam performed and documented should be clinically relevant based on the nature of the patient’s presenting problem. If the problem does not warrant a comprehensive exam and an expanded problem focused history, an auditor will discount them and likely challenge the level of service. To use an extreme example, it is possible to perform and document a comprehensive history and examination for a patient with a common cold and no comorbidities, but it would be difficult, if not impossible, to find someone who would agree that such a presenting problem merited a level 5 E/M service.