Coding Guidelines

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Coding Guidelines

Level of Visit

History^a

Physical Examination

Medical Decision–Making^b

Time^c

2—Problem Focused

HPI^b = 1–3

ROS = 0

PFSH = 0

1 organ system

(limited to affected body area)

Straightforward

10 min

3—Expanded Problem Focused

HPI = 1–3

ROS = 1

PFSH = 0

2–7 (limited examination of affected area plus 2–6 related areas)

Low

15 min

4—Detailed

HPI = 4+

ROS = 2–9

PFSH = 1 (pertinent)

2–7 (extended examination of affected areas and other systems)

Moderate

25 min

5—Comprehensive

HPI = 4+

ROS = 10+ (or 10 and "remainder negative")

PFSH = 2 or 3 if require all 3 factors

8+ or complete (general multisystem examination, not body areas)

High

45 min

HPI, history of present illness; ROS, review of systems; PFSH, past, family, and social history.

^aSee "History of Present Illness" chart. For ROS, ENT is one system.

^bBased on level of risk, number of diagnoses, and complexity of data (need 2 out of 3 – see "Medical Decision-Making" and "Risk of Complications" charts).

^cMore than 50% of time spent in face-to-face counseling (trumps all others).

History of Present Illness

Timing—includes time, frequency, and number of occurrences.

Quality—descriptive terms (eg, sharp, dull, stabbing, acute, chronic, improving).

Severity—measurement of discomfort, nonverbal symptoms (eg, wincing, doubled over), comparison to previous pain, and extent of process (eg, staging, grade of burn).

Context—where patient is when symptoms occur; what patient is doing (includes “fell from chair”).

Location—where on the body the signs and symptoms are located.

Duration—from what starting point.

Associated signs and symptoms—pertinent positive and negative results relating to chief complaint (non-review of systems).

Modifying factors—medications or treatments tried.

Medical Decision-Making

Level of medical decision-making is determined by 2 out of 3 of the following:
*Level of Medical Decision-Making*	*Risk of Complications*	*No. of Diagnoses and Management Options*	*Data to Be Reviewed (see “Risk of Complications” chart)*
Straightforward	Minimal (see “Risk of Complications” chart)	1 self-limited OR 1 established problem	<1 point (see “Risk of Complications” chart)
Low	Low (see “Risk of Complications” chart)	2 self-limited/minor problems OR 2 established problems OR 1 established worsening OR 1 stable chronic	2 points (see “Risk of Complications” chart)
Moderate	Moderate (see “Risk of Complications” chart)	1 new problem (no additional workup) OR 3 established problems OR 2 established problems, 1 worsening	3 points (see “Risk of Complications” chart)
High	High (see “Risk of Complications” chart)	1 new problem + additional workup OR 4 established problems OR 2 established problems, 1 worsening	4 points (see “Risk of Complications” chart)

Risk of Complications

Risk is determined by 2 out of 3 of the following:
*Level of Risk*	*Presenting Problems*	*Diagnostic Procedures*	*Management Options*
Minimal	1 self-limited	-Laboratory test (venipuncture)	-Bandages/rest/dressing
Low	2 or more self-limited OR 1 stable chronic OR acute uncomplicated	-Radiograph (single) -Physiologic test (spirometry) -Superficial needle box -Arterial laboratory test	-Over-the-counter drugs -Minor surgery -Occupational therapy
Moderate	1 or more chronic with mild exacerbation OR 2 or more stable OR acute with systemic symptoms OR acute complicated OR undiagnosed new problem with uncertain prognosis	-Multiple radiographs -Computed tomography, magnetic resonance imaging -Cardiothoracicimaging -Lumbar puncture -Joint aspiration -Deep needle box	-Prescription drugs -Closed fracture treatment -Minor surgery with risks -Elective major surgery
High	1 or more chronic with severe exacerbation OR acute illness with threat to life and limb OR abrupt change in neurologic status	-Discography -Myelography -Arthrogram	-Elective major surgery with risks -Controlled substance -Drug therapy with intensive monitoring

Data to Be Reviewed

Count the number of points.
1 point	Order and/or review laboratory test
1 point	Order and/or review radiology test
1 point	Order and review other test (eg, electrocardiogram)
1 point	Decision to obtain old records or additional history

2 points	Direct visualization of laboratory results or image
2 points	Review and summarize old records
2 points	Obtain history from other than patient
2 points	Discuss case with other provider

The recommendations in this publication do not indicate an exclusive course of treatment or serve as a standard of medical care. Variations, taking into account individual circumstances, may be appropriate. This content is for informational purposes only. It is not intended to constitute financial or legal advice. A financial advisor or attorney should be consulted if financial or legal advice is desired.

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