Within the evaluation and management (E/M) coding system, a complex set of elements are used to determine the level of care and, ultimately, the correct CPT code for billing. The key elements are history, physical exam and medical decision-making. Contributing elements are counseling, coordination of care, nature of the presenting problem and time.
The nature of presenting problem is clearly explained in the CPT book. At the beginning of the section on E/M codes, you'll find a number of light green pages titled "Evaluation and Management (E/M) Guidelines," which include a section on "Nature of Presenting Problem." The section lists five types of presenting problems and offers a brief description of each.
Determining Level of Care
Just because a provider documents a patient encounter at the maximum level, it doesn't qualify for a level-five visit if the reason for the visit was a minor problem. You can generate pages of medical records, but documentation doesn't determine the level of care, the nature of presenting problem does. I like to think of it as an umbrella that overshadows all of the other elements.
For example, if you obtain and document an extended (four or more elements) history of present illness (HPI), a complete (10 or more areas) review of systems (ROS) and a complete past medical, family and social history (PMFSHx), and then perform and document a comprehensive exam (two or more bullets in nine or more areas or a complete single organ system exam) on an established patient who came in for a sore throat, you'd be hard-pressed to justify much more than a level-three visit based on the nature of presenting problem.
If, however, the patient had a number of other issues, such as fever, headache, earache, cough and wheezing, nausea and vomiting and signs of dehydration, it would be much easier to justify a level-five visit. Again, the nature of presenting problem (multiple systems, morbidity and mortality risk if not treated) determines the medical necessity for history, exam and medical decision-making.
I once saw a patient exactly like this. A sore throat was his primary complaint, but during the course of the history, I discovered that he had been ill for more than a week. He had a high fever and all of the other symptoms I just described. He was weak and had passed out at home.
It turned out he had strep that had progressed to full-blown sepsis. He died three weeks later in an intensive care unit. Although his chief complaint was only a sore throat, the other issues discovered by obtaining a complete history (HPI, ROS, PMFSHx) revealed a far more serious situation.
5 Types of Presenting Problems
Let me outline the five types of presenting problem described in the CPT book.
Minimal: A problem that might not require the presence of the physician, but service is provided under the physician's supervision.
Self-limited or minor: A problem that runs a definite and prescribed course, is transient in nature and is not likely to permanently alter health status or that has a good prognosis with management and compliance.
Low severity: A problem where there is little to no risk of mortality without treatment; full recovery without functional impairment is expected.
Moderate severity: A problem where there is moderate risk of mortality without treatment, an uncertain prognosis or increased probability of prolonged functional impairment.
High severity: A problem where there is a moderate to high risk of mortality without treatment or high probability of severe, prolonged functional impairment.
To help make sense of these five types of presenting problem, the CPT book includes a fairly exhaustive list of clinical examples in Appendix C. An interesting exercise is to look at the code you use most often and read the clinical examples associated with it. You'll find that the patients in the 99213-level examples often are stable and are being seen for routine follow-up visits or minor new problems. In the 99214-level examples, patients are being seen for new problems or exacerbations to existing conditions. They often need new tests, medications or interventions.
You'll find clinical examples for new patients, established patients, hospital services, consultations, emergency department services and a few other areas of patient care. These examples serve as an excellent point of reference.
Every Patient, Every Visit
I have always advocated that a complete HPI, ROS and PMFSHx be obtained on every visit. The HPI has to stand alone. That means anyone reading today's chart note should be able figure out what is going on by reading today's HPI. In the case of a follow-up visit, referring to the previous note or notes is acceptable, but today's note should describe any progression of the disease process, the response to treatment, side effects, new symptoms and so forth.
On every visit, at least the ROS and PMFSHx should be reviewed and updated as needed. A simple statement in today's note that they were reviewed and that no changes were needed is sufficient. Obviously, any new findings should be documented. Remember to state specifically what was reviewed, by whom and on which date to fulfill the requirements of accurate documentation.
This sounds like a vast amount of work, but remember that training your ancillary staff to ask a few simple questions when a patient is seen in follow-up can satisfy the need for updated information.
A review and update of the previous ROS, followed by inquiry about changes in family and social history, also can be recorded at this point. All of this can be done before you see the patient-you simply review the updated information at the beginning of the visit, ask any clarifying questions and then get on with the visit.
The process serves as the basis for considering the nature of the presenting problem. Once we have this information, we can look at the big picture (the patient's overall health) and have a greater understanding of the complexity or simplicity of the situation. We then can focus on the specifics of the sore throat (or whatever the complaint). If we discover during the HPI and ROS that the patient is has a fever, syncope and low blood pressure, then perhaps a "self-limited or minor" sore throat isn't the entire picture, but high-severity sepsis is the nature of presenting problem.
Jim Meeks is a family practice PA who works in Orem, Utah, and is the founder of Medical Professional Education and Consultation Services (MPECS). He is the president-elect of the Association of Family Practice Physician Assistants.