Determining the Appropriate Components: History, Examination, and Medical Decision Making
When evaluating a patient encounter, it is essential to determine the correct level for each component—History, Examination, and Medical Decision Making (MDM). This not only impacts coding and billing but also ensures that the documentation accurately reflects the complexity of the visit.
History
The History component is based on the information you collect about the patient’s current problem, past medical history, and related reviews of systems. It typically falls into one of the following levels:
- Problem-Focused History: A brief review related only to the patient’s presenting complaint. Use this when the issue is straightforward.
- Expanded Problem-Focused History: A more detailed review that includes a limited review of systems and pertinent past history related to the presenting problem. This level is used for slightly more involved cases.
- Detailed History: A comprehensive review that examines multiple systems and provides an in-depth history. This is necessary when the patient’s condition is complex or multifactorial.
How to determine which applies: Ask yourself how much information is needed to understand and manage the patient’s problem. A simple, isolated complaint might require only a problem-focused history, while a patient with several issues or unclear symptoms likely requires a detailed history.
Examination
The Examination component reflects the physical exam you perform. The exam can be categorized as:
- Problem-Focused Examination: A targeted exam of the affected area or system.
- Expanded Problem-Focused Examination: An exam that includes additional systems or areas closely related to the problem.
- Detailed Examination: A more extensive exam that covers a broader set of systems.
- Comprehensive Examination: A full and complete exam that reviews all pertinent systems, used in very complex cases.
How to determine which applies: Evaluate the complexity of the patient’s complaint. A localized problem might need only a problem-focused exam, whereas a patient with multiple issues or a diffuse presentation could require a detailed or comprehensive exam.
Medical Decision Making (MDM)
Medical Decision Making is based on the complexity of establishing a diagnosis and developing a management plan. It is generally divided into:
- Straightforward MDM: Appropriate for visits with minimal data review, limited diagnostic options, and low risk. Use this for very simple cases.
- Low Complexity MDM: Involves a moderate amount of data review and slightly increased risk, used for cases that are a bit more involved than straightforward visits.
- Moderate Complexity MDM: Applies when multiple factors are considered in the diagnostic process, requiring more data review and presenting moderate risk.
- High Complexity MDM: Indicates extensive data review, multiple diagnoses or management options, and high risk, appropriate for very complex cases.
How to determine which applies: Consider the number and complexity of the problems addressed, the volume and complexity of data reviewed (e.g., labs, imaging, consultations), and the overall risk of complications or morbidity. More complex cases, involving multiple active issues, will necessitate a higher level of MDM.
Conclusion
In summary, determining the correct levels for History, Examination, and Medical Decision Making involves a thoughtful review of the patient’s presentation. Ask yourself:
- How much information is needed to understand the patient’s problem?
- How extensive should the physical exam be to address the issues present?
- What is the level of risk or complexity associated with diagnosing and managing this patient?
By answering these questions, you can choose the appropriate components and ensure your documentation supports the level of service provided.
Disclaimer: The information provided in this post is for educational purposes only. Always refer to the latest CPT guidelines and payer policies when coding patient encounters.