History: The history of present illness (HPI) is at an extended level, the review of systems (ROS) is at an extended level, and all three of the past family social histories (PFSH) were documented. (Note: It is acceptable to record and document all or part of the PFSH and refer back to the original documentation if there has been no change.) To obtain the history level, all three of the components—HPI, ROS, and PFSH—have to be obtained. According to the documentation, this history is at a detailed level.
Examination: Based on 1995 documentation guidelines, there were nine body areas and systems examined, making this a comprehensive exam.
Medical decision making (MDM): The number of diagnoses was greater than four points—one established problem stable equals one point, one established problem worsening equals two points, and one new problem with work-up requested equals four points. This adds up to a total of seven points, making this component extensive.
The amount of data reviewed and/or ordered equals two points—one point for the labs and one point for the X-rays—making the amount and complexity of data component limited.
Lastly, the level of risk was high because of the drug therapy requiring intensive monitoring for toxicity.
The MDM is of high complexity.
Only two out of the three components are needed for the determination of the MDM level.
Final summation: History was detailed, the exam was comprehensive, and the MDM was of high complexity, making this a level-five established office visit.
