Primary Care Coding Alert

Question: We see a lot of patients who come in with a shopping list of problems that are often stable. For such a visit, should I use a lower-level E/M?

Florida Subscriber

Answer: Such visits can actually involve more history and medical decision making than you may give yourself credit for and may ultimately support a higher-level office visit. You-re often determining whether

prescription medication is working (moderate risk related to medical decision making).

Key: When treating chronic conditions, think 1997 E/M guidelines. These count documentation of the status of one to two chronic conditions as an expanded problem focused history of present illness (HPI) and

recording the status of three or more chronic conditions as a comprehensive HPI.

Example: You see a patient for follow-up of medical problems (chief complaint). In the HPI, you note, "The 63-year-old female with hypertension. Blood pressure has been controlled. Denies headaches. Her back

pain is stable, but she still has minor tingling after sitting for long periods. Her osteosporosis is now stable. Recent bone density test showed no further deterioration."

Under assessment/plan, you note the conditions- status as:

- Hypertension, stable, continue meds

- Back pain, stable, continue meds

- Osteosporosis, stable, continue meds.

For the remaining history, you document under past medical family social history (PFSH) that the patient is "not exercising" (1 SH, pertinent). The HPI includes three elements of ROS, which counts as extended

ROS. Expanded problem focused HPI + extended ROS + pertinent PFSH = detailed history.

Your exam includes the constitutional, cardiovascular, and musculoskeletal systems, which counts as an expanded problem-focused exam.

Under medical decision making, you have three stable problems (three points) and review of radiology test (one point). The three chronic conditions and prescription drug management point to a moderate level of

risk, giving you multiple diagnoses, moderate risk, and low data, which supports moderate complexity MDM. This level MDM combined with detailed history and expanded problem focused exam supports a level-four

established patient visit (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 -).