What do you need to accurately assign an E/M procedure code?

PO Coding Project

A Guided Walk Through for CPT/HCPCS Coding of Case013

Getting to know your document:

Since these PO cases were created, and not “authentic” records so they are not an entirely full patient record, thus some information may not be present that you would typically find in a patient encounter. However, there is enough information here to accurately assign procedure codes.

In this scenario, page one is a standard patient summary, or face sheet. We take note of things like that patient’s age, sex, etc. Also of importance, is the location, however you know this is a physician’s office record. In many cases you will need to determine if this is a new or established patient. The documentation on that will vary based on the type of EHR used. For the sake of this project, we are saying all patients are established.

What do you need to accurately assign an E/M procedure code:

You might remember from Chapter 7, there are some key criteria you need to know to accurately assign an E/M procedure code.

First question: What are the criteria for determining the level of service: 2/3 key components, 3/3 key components, time or other?

Our case is an established patient, so we need to meet 2/3 key components of a code to assign it.

This means, our code assignment is already narrowed down to the subsection within the E/M section to, Established Patient, 99211-99215.

What do you need to accurately assign an E/M procedure code:

Next question, What level of history was taken by the provider?

The history is designed to act as a narrative which provides information about the clinical problems or symptoms being addressed during the encounter.  The history is composed of four building blocks:

Chief complaint (CC)

History of present illness (HPI)

Review of systems (ROS)

Past medical, family and social history (PFSH)

All levels of history require a chief complaint and some form of HPI (or Interval History), but not all levels of history require an ROS or PFSH.

The E/M guidelines recognize four “levels of history” of incrementally increasing complexity and detail:

Problem Focused

Expanded Problem Focused



There are many flowcharts/code builders that you can use to help identify these levels of history more clearly. See one example here:

Using our case, the following can be chosen based on documentation:

To begin, the HPI:

Our focus here is on the history of present illness. Related to his chief complaint, there is really only the “location” of pain or discomfort documented here. So, that gives us 1 element for HPI. This already directs us to the “Brief” column.

Next, the ROS:

Not all ROS are going to be labeled ROS so sometimes you need to read through the documentation to pick it out. It could look something like this:


GENERAL:  The patient complains of fatigue. No headaches or dizzy spells.

HEENT:  The patient does have glaucoma. She has decreased vision and is blind in the right. Sinuses:  No complaints.

CARDIOPULMONARY:  She gets swelling of the legs but no chest pain. She does have shortness of breath, no wheezing.

GASTROINTESTINAL:  She has frequent heartburns. Has known gastroparesis. Denies both diarrhea and constipation, blood or mucus.

GENITOURINARY:  She denies dysuria, bleeding and incontinence.

MUSCULOSKELETAL: She has a lot of arthritic complaints including stiffness, weakness.

She has slow healing. The patient seems to be feeling well

Or this:

REVIEW OF SYSTEMS:  The patient denies any fever, weight change. Denies any sore throat, ear pain, rhinorrhea. Denies any double vision, blurred vision or eye pain. Denies any shortness of breath, cough or pleuritic chest pain. The patient denies any nausea, vomiting or diarrhea. The patient does not have any dysuria, frequency or urgency. The patient does have myalgias in the back and legs from the sickle cell pain but no bony tenderness. The patient does have a history of anemia and has required transfusions in the past. He denies any bleeding or easy bruising.

NOTE: Our case does not have a documented ROS.

Our last element in the History is PFSH:

Past History

Prior illnesses or injuries

Prior operations

Prior hospitalizations

Current medications Note: Documenting these is part of the criteria for reporting Physician Quality Reporting System PQRS measure 130


Age-appropriate immunization status

Family History

The health status or cause of death of parents, siblings and children

Diseases or eye problems of family members that may be hereditary or place the patient at risk, e.g., family history of diabetes, glaucoma, strabismus, amblyopia, cataracts before age 50 and age-related macular degeneration

Social History

Marital status and/or living arrangements

Current employment helpful for glasses selection/needs

Use of drugs, alcohol or tobacco

Our PFSH review covers the medications, previous illnesses, etc. All of these count as our Past History, for this patient. There is no Family History documented. The fact that his veteran status is mentioned is enough to also check “Social”. This brings us to the ‘Complete” level of PFSH with 2 areas being done.

To calculate the level of History, we take all our checked boxes, and if there are no categories with all there checks, to determine our level we then move to the furthest to the left to determine.

One element down, two to go!

Next is the physical examination:

The systems are broken out like this:

Our review of the Physical Exam:

So, the physician documents:

General appearance (patient is alert, oriented, not in any distress, pleasant)

Respiratory (chest is clear)

Cardiovascular (NSR – normal sinus rhythm)

Gastrointestinal (Abdomen: soft, benign, no masses felt and rectal exam)

Last component of our E/M Procedure is Medical Decision Making:

This is arguably the most important of the three key components because the Medical Decision-Making (MDM) reflects the intensity of the cognitive labor performed by the physician. The official rules for interpreting the MDM are identical for both the 1995 and 1997 E/M guidelines. There are four levels of MDM of incrementally increasing complexity:


Low Complexity

Moderate Complexity

High Complexity

Physicians must stratify the MDM into one of the above levels of complexity based on:

The nature and number of clinical problems

The amount and complexity of the data reviewed by the physician

The risk of morbidity and mortality to the patient.

Risk is determined by referring to the four levels of medical jeopardy





To assist you in this often difficult task, the next slide will explain a point system to help identify decision-making.

Problem Points

Problems Points
Self-limited or minor (maximum of 2) 1
Established problem, stable or improving 1
Established problem, worsening 2
New problem, with no additional work-up planned (maximum of 1) 3
New problem, with additional work-up planned 4

An example of a “self-limited or minor” problem may be a common cold or an insect bite.  An “established problem” refers to a diagnosis which is already known to the examiner, such as hypertension, osteoarthritis or diabetes.  An example of a “new problem with no additional work-up planned” may be a new diagnosis of essential hypertension.  Examples of “new problem, with additional work-up planned” may include any new clinical issue which requires further investigation such as chest pain, proteinuria, anemia, shortness of breath, etc

Data Reviewed Points

Data Reviewed Points
Review or order clinical lab tests 1
Review or order radiology test (except heart catheterization or echo) 1
Review or order medicine test (PFTs, EKG, cardiac echo or catheterization) 1
Discuss test with performing physician 1
Independent review of image, tracing, or specimen 2
Decision to obtain old records 1
Review and summation of old records 2

Our level of medical-decision making:

After the examination, the physician documents the assessment and plan.

To complete our problem point system, the anal tear and hemorrhoids are new diagnoses and have additional work-up planned (surgical consult).

To complete the data reviewed point area, we have none. There were no records reviewed, order of additional tests, etc.

Medical-Decision Making (continued)

Assigning risk:

Risk Level Presenting Problems Diagnostic Procedures Management Options Selected
Minimal Risk   Requires ONE of these elements in ANY of the three categories listed ·  One self-limited or minor problem, e.g., cold, insect bite, tinea corporis Laboratory tests Chest X-rays EKG/EEG Urinalysis Ultrasound/Echocardiogram KOH prep Rest Gargles Elastic bandages Superficial dressings
Risk Level Presenting Problems Diagnostic Procedures Management Options Selected
Low Risk  Requires ONE of these elements inANY of the three categories listed Two or more self-limited or minor problems One stable chronic illness, e.g., well controlled HTN , DM2, cataract Acute uncomplicated injury or illness, e.g., cystitis, allergic rhinitis, sprain Physiologic tests not under stress, e.g., PFTs Non-cardiovascular imaging studies with contrast, e.g., barium enema Superficial needle biopsy ABG Skin biopsies Over the counter drugs Minor surgery, with no identified risk factors Physical therapy Occupational therapy IV fluids, without additives

Medical-Decision Making (continued)

Assigning Risk:

Risk Level Presenting Problems Diagnostic Procedures Management Options Selected
Moderate Risk Requires ONE of these elements inANY of the three categories listed Two stable chronic illnesses One chronic illness with mild exacerbation or progression Undiagnosed new problem with uncertain prognosis (e.g., lump in breast) Acute complicated injury, e.g., head injury, with brief loss of consciousness Physiologic tests under stress, e.g., cardiac stress test, fetal contraction stress test Diagnostic endoscopies, with no identified risk factors Deep needle, or incisional biopsies Cardiovascular imaging studies, with contrast, with no identified risk factors, e.g., arteriogram, cardiac catheterization Obtain fluid from body cavity, e.g., LP/thoracentesis Minor surgery, with identified risk factors Elective major surgery (open, percutaneous, or endoscopic), with no identified risk factors Prescription drug management Therapeutic nuclear medicine IV fluids, with additives Closed treatment of fracture or dislocation, without manipulation

Medical-Decision Making (continued)

Assigning Risk:

Risk Level Presenting Problems Diagnostic Procedures Management Options Selected
High Risk Requires ONE of these elements in ANY of the three categories listed One or more chronic illness, with severe exacerbation or progression Acute or chronic illness or injury, which poses a threat to life or bodily function, e.g., multiple trauma, acute MI, pulmonary embolism, severe respiratory distress, progressive severe rheumatoid arthritis, psychiatric illness, with potential threat to self or others, peritonitis, ARF An abrupt change in neurological status, e.g., seizure, TIA, weakness, sensory loss Cardiovascular imaging, with contrast, with identified risk factors Cardiac EP studies Diagnostic endoscopies, with identified risk factors Discography Elective major surgery (open, percutaneous, endoscopic), with identified risk factors Emergency major surgery (open, percutaneous, endoscopic) Parenteral controlled substances Drug therapy requiring intensive monitoring for toxicity Decision not to resuscitate, or to de-escalate care because of poor prognosis

Our medical-decision making:

To use the elements described in previous slides, they can be summarized here in our chart.

We had 4 problem points, 0 data reviewed and low risk (per the risk chart). Since we do not have any column with 2 or 3 identified, we use the column with the second mark from the left, in our case Low Complexity for MDM.

Building our E/M Level:

We have identified our key components:

History – problem focused

Examination – expanded problem focused

MDM – Low complexity

Remember for an established patient, we need two out of three key components met for that level.

Lastly, some facilities will capture the following:

99070 – Supplies and materials (except spectacles), provided by the physician or other qualified health care professional over and above those usually included with the office visit or other services rendered (list drugs, trays, supplies, or materials provided)

E0190 – Positioning cushion, any shape

"Get 15% discount on your first 3 orders with us"
Use the following coupon

Order Now
0 replies

Leave a Reply

Want to join the discussion?
Feel free to contribute!

Leave a Reply

Your email address will not be published. Required fields are marked *