We were instructed to pull the information from the HPI and MDM. The exam portion of
the visit is part of the CPE so we can not use.
That's what I do, too. You only need 2/3 components for an established sick visit, so drop the exam out altogether. (If there's a sick and a well visit in the same visit, the sick E/M will nearly always be considered "established",
even on the patient's first visit.
Here's how I figure out my problem E/M level (If there's a better way, I'm all ears!):
The only areas that you can use to easily distinguish a "sick" E/M from a "preventive" one, are the HPI and MDM, since they're unique to problem-oriented codes. Pick your code based on the
nature of the problem (or how severe/complicated the problem is), then make sure you've got enough HPI and MDM to support
that code. If you come up with
less, go with whatever level you can meet. If you come up with
more, stick with what was medically necessary to evaluate and treat the patient's presenting problem. You'll never assign a higher level sick E/M than was medically necessary for the encounter.
