Primary Care Coding Alert

Question: A patient comes in with a chief complaint of -increasing forgetfulness.- How could I apply the mini mental status exam (MMSE) into the history component's history of present illness (HPI)? Should I count it as context? Or could it be part of the E/M level's medical decision making (MDM)?

Indiana Subscriber

Answer: You note that -increasing forgetfulness- is the patient's chief complaint. The chief complaint isdistinct from the HPI. Documentation of the development of the patient's increasing forgetfulness, however, could be counted under HPI. Here's how:

Under HPI, a statement of the condition's quality, which may be a description of discomfort, could be relevant. For example, a statement that the forgetfulness is chronic lends to the HPI.

Context, on the other hand, is a description of where the patient is or what he is doing when the signs or symptoms begin. A context note could indicate the forgetfulness has increased since, for instance, the patient fell from the porch.

If the note was part of the questions the FP asked the patient, he could alternatively count forgetfulness under psychiatric review of systems (ROS). Be careful to count the statement only once under HPI or ROS.

MMSE performance and documentation may contribute to the encounter's exam and MDM level. The 1997 General Multi-System Examination under the Psychiatric organ system includes the following potential elements:

- brief assessment of mental status including orientation to time, place, and person

- recent and remote memory - mood and affect (such as depression, anxiety,agitation).

When selecting the MDM level, the FP could include how the MMSE's results impacted his assessment of the patient's condition and his recommendations for additional data (for instance, tests ordered) or management options.