Primary Care Coding Alert

Question: When a patient comes into the office complaining of chest pain, we often order lab work, an ECG, and send the patient to the hospital. These instances involve moderate to high risk but we do not perform a complete review of systems

(ROS) due to the presenting problem's emergent nature. Will these be level-four or -five established patient office visits?

Georgia Subscriber

Answer: There is no rule that stipulates which level E/M code you will use every time for the same chief complaint. Instead, you will choose the appropriate level based on the medically necessary history, exam, and medical decision making

(MDM) that you perform and document at each encounter. Probable combos for a patient presenting with a possible heart attack include detailed history + detailed/comprehensive exam + mod/high MDM. Since an established patient visit requires

2 of 3 key components, the MDM, plus the amount of exam, may ultimately determine whether the encounter is a level four (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 - Usually, the presenting problems are of moderate to high severity -) or five (99215, - a comprehensive history; a

comprehensive examination; medical decision making of high complexity -). Here are the breakdowns:

MDM: Assuming chest pain is a new problem that the patient is having, you would receive four points in the "Number of Diagnoses or Treatment Options" area for the new problem to provider with additional work-up planned on the standard

documentation worksheet. You would receive a point for ordering lab work and a point for ordering the ECG for a total of two points in the "Amount and/or Complexity of Data to be Reviewed" section. Because the diagnoses level puts you at a high

level and the data amount is at a low level, the risk will determine whether the MDM is high complexity (if risk is high) or moderate complexity (if risk is moderate).

History: You indicate in your question that these scenarios do not involve performing a complete ROS (10 or more systems, or some systems with statement "All others negative"), which a comprehensive history requires. Your history taking,

however, probably involves asking the patient about the severity, duration, quality, context, etc. of the pain (history of present illness [HPI]) and any past personal or family history of heart disease (past medical, family, social history [PFSH]).

Therefore, your HPI will probably involve at least four (extended) HPI elements and 1 (pertinent) PFSH element. You would also at minimum ask questions about the constitutional and cardiac systems. Reviewing 2-9 systems (extended) counts

as detailed ROS. Extended HPI + extended ROS + pertinent PFSH = detailed history.

Examination: Now if you examine eight or more systems ��" such as constitutional, eyes, ENT, detailed cardio (a given), respiratory, skin, neuro, and psychological, you-ll be at a comprehensive exam. If the severity didn't allow for anything other

than constitutional (vitals, general appearance) and detailed cardio, you may still be at a detailed exam.