Coding Corner Answers
- D: Extensive. This is just one of the three parts for the medical decision-making component of an E/M visit. The medical decision-making component comprises three parts: number of diagnoses or treatment options, the amount and/or complexity of data to be reviewed, and the risk of complications and/or morbidity or mortality.
- A: True. A chief complaint must be documented in the patient’s medical record for every office visit. Not having one could classify the visit as not medically necessary.
- E: Four, or the status of at least four chronic or inactive conditions. An extended HPI consists of four of the seven HPI elements (i.e., location, quality, severity, duration, timing, context, modifying factors, and associated signs and symptoms), or the status of at least three chronic or inactive conditions.
- D: To reach a comprehensive history level, all four parts of the history element must be obtained: chief complaint; extended HPI; complete review of history; and the past, family, and social history. For a new patient, consultation, or initial hospital visit, all three of the past medical, family, and social history must be documented, but for an established or emergency room patient only two of the three must be documented to reach a comprehensive level of history. An extended HPI and a complete review of history must also be obtained.
- D: High risk. The risk of complications and/or morbidity or mortality is broken into three categories: presenting problems, diagnostic procedures ordered, and management options selected. A diagnosis of severe rheumatoid arthritis is categorized under presenting problems at a high level of risk.
The ACR has a certified coder available to review a small sampling of your practice’s medical charts—up to five charts for each physician—at no cost to ACR members. Contact Melesia Tillman, CPC, CPC-I, CRHC, CHA, at (404) 633-3777, ext. 820, or [email protected] with your questions today.
