1995 Documentation Guidelines FAQ

The documentation guidelines were designed by Medicare to define content of documentation for History, Physical Examination and Medical Decision Making. The Guidelines were initially developed and published in 1995 with general content requirements for each of the key elements of the Evaluation and Management levels. Subsequent to the initial format, CMS published the 1997 guidelines. This version divided documentation guidelines for the same three key elements but designed a point system for qualifying the level of physical examination which was based on each of the organ system examinations. Physicians were given the choice to use either the 1995 or 1997 guidelines but are free to select the version most favorable. In emergency medicine, the 1995 documentation guidelines are the most frequently used and well worth reading. (See link in FAQ 5.)

CMS has said that the guidelines are for Medicare only. Of course any other carrier may adopt whatever payment policy they choose. Many ED practices have implemented the Documentation Guidelines for all payers as they provide an objective means to determine the content of the Evaluation and Management level of service. As the CPT definitions are somewhat subjective, they provide less definition to the requirements for scoring the history, physical examination and medical decision making.

Yes, as long as there are specific references to individual elements that can be recognized according to those listed in the Documentation Guidelines. The physician is required to sign the completed template.

When coding for a claim that will be submitted to Medicaid (depending upon the state) and/or Medicare, you must use the CMS Documentation Guidelines for Evaluation and Management services. Some groups choose to follow CMS' guidelines across the board for all payers. Others follow CMS guidelines for Medicare and other governmental payers and apply CPT rules for all other patients. Keep in mind that for other payers, the guidelines you use will most likely depend upon whether or not you contractually participate with the payer. If you participate, you must use the payer's designated guidelines and comply with associated payer policies. If you do not participate with a payer, then usually the CPT guidelines pertain.

CPT Evaluation/Management (E/M) guidelines are generally less quantitative, providing the clinician some qualitative latitude based on the medical necessity of a particular clinical encounter. CMS is obligated to formally notify providers of its modifications to CPT requirements; in the absence of such specific notifications CPT requirements are understood to be in effect for Medicare patients. For E/M codes, CMS instructs their contractors to audit physician documentation by either CMS' 1995 Documentation Guidelines (DG) or their 1997 DG, whichever most benefits the physician. The vast majority of Emergency Medicine physician groups use CMS' 1995 DG over the 1997 DG. Consequently, this FAQ will focus on the 1995 DG for CMS discussions.

The 1995 CMS guidelines were issued as a joint effort between the AMA and HCFA (now CMS) to help physicians understand the CMS guidelines in context with the AMA's Current Procedural Terminology (CPT) coding system.  Subsequently, Medicare contractors adopted a variety of proxy tools to further qualify and quantify physician documentation elements toward supporting an Evaluation/Management level of service. Adaptations of the Marshfield Clinic Scoring tool and other CMS contractor audit tools seek to measure application of documentation guidelines across multiple physician specialties

There are seven components contained within Evaluation and Management (E/M) service guidelines: history, exam, medical decision-making, counseling, coordination of care, nature of presenting problem, and time. The first three components are considered the key components used in selecting the appropriate Emergency Medicine E/M service code. Note: Time is not a descriptive component for the emergency department levels of E/M services 99281-99285 in 2022.

The CMS and CPT history components are the same. History documentation includes the history of present illness (HPI), review of systems (ROS) and past medical, family, and social history (PMFSH). These elements may be documented separately or contained within one statement.

The E/M guidelines recognize four levels, and all require a chief complaint:
• Problem Focused: Brief history of present illness or problem.
• Expanded problem focused: brief HPI, problem pertinent ROS.
• Detailed: Extended HPI, problem pertinent ROS plus a limited number of additional systems. Pertinent PMFSH related to the patient's problems.
• Comprehensive: extended HPI, ROS that is directly related to the problems identified in the HPI plus all additional body systems, and a complete PMFSH.

Yes, as you see in the table below CMS has expanded upon the more general language for brief and extended HPI and conventionally adopted specific numerical requirements. CPT has 7 HPI elements, and CMS has 8 HPI elements.  

Yes, as you see in the table below CMS has expanded upon the more general language for problem pertinent, extended, and complete ROS and conventionally adopted specific numerical requirements. CMS allows the statement "all other systems reviewed and are negative" to suffice for a complete ROS provided problem pertinent positives and/or negatives are documented.

*Of note, within the CPT definition of a Comprehensive history is the description: "review of systems which is directly related to the problem(s) identified in the history of the present illness plus a review of all additional body systems." 

Yes, as you see in the table below CMS has expanded upon the more general language for problem pertinent and complete Past Medical/Family/Social History and adopted specific numerical requirements.

*Of note, within the CPT definition of a Comprehensive history is the description: "chief complaint; extended history of present illness; review of systems which is directly related to the problem(s) identified in the history of the present illness plus a review of all additional body systems; complete past, family and social history."

** For CMS, at least one specific item from two of the three past medical, family, and social history areas must be documented for a complete PFSH for the following categories of E/M services: office or other outpatient services, established patient; emergency department; subsequent nursing facility care; domiciliary care, established patient; and home care, established patient.

For CMS, at least one specific item from each of the three (3 of 3) past medical, family, and social history areas must be documented for a complete PFSH for the following categories of E/M services: office or other outpatient services, new patient; hospital observation services; hospital inpatient services, initial care; consultations; comprehensive nursing facility assessments; domiciliary care, new patient; and home care, new patient.

Yes. CMS allows for situations where the physician is unable to obtain a history from the patient or other source when completing the History. If the patient is unable to give a history, the practitioner must describe the patient's condition or other circumstance which precludes obtaining a history. A foreign language barrier does not qualify. Common examples include altered mental status, dementia, and also urgency of condition. It is advisable for the physician to make attempts to gather the History from other sources and document as much as possible. CMS also allows for the ROS and past history to be recorded by ancillary staff or the patient, as long as the practitioner documents they reviewed and supplemented and/or confirmed the information. 

"The only definitive statement in the 1995 and 1997 Documentation Guidelines regarding who can obtain/document a patient's History states: "The ROS and/or PFSH may be recorded by ancillary staff or on a form completed by the patient. To document that the physician reviewed the information, there must be a notation supplementing or confirming the information recorded by others." Verbal guidance from CMS officials and individual CMS contractor's policy statements indicate that the physician or qualified NPP (Advanced Practitioner) must perform and document the HPI.  For guidance on documentation requirements for residents, Advanced Practitioners (NPP's), or scribes, please refer to the relevant FAQ.

Historically, a provider must choose to follow either the 1995 Documentation Guidelines or the 1997 Documentation Guidelines, but not a combination of the two. However, CMS released an update that states for services performed on or after September 10, 2013 physicians may use the 1997 documentation guidelines for an extended history of present illness along with other elements from the 1995 guidelines to document an evaluation and management service.

Some confusion exists over this issue. While it is true that a single item cannot be used twice within the same section of the history (either HPI, ROS or PFSH), it appears that a single item may be used in 2 separate historical sections. Based on correspondence with CMS representatives, ACEP believes that under the CMS documentation guidelines, the use of a single historical item in both the HPI and ROS is recognized as an acceptable practice. These letters can be viewed on the ACEP web site. As with many aspects of the documentation guidelines, individual Medicare contractor variation may exist and members are advised to seek clarification with local representatives.

For example, "Nightly," in the statement 'nightly leg pain' could not be credited for both duration and timing in the HPI. However, in the statement 'chest pain with shortness of breath', "shortness of breath" could be credited as an associated sign and symptom in the HPI and also credited in the Respiratory system of the ROS for the same record.

CMS 1995 and 1997 Documentation Guidelines both state that after pertinent positives and negatives have been addressed, the statement "all other systems are negative" meets CMS documentation requirements for a complete ROS.  Physicians are reminded that pertinent positive or negative responses should be individually documented.  When a complete ROS is performed, the statement "all other systems are negative" is permissible for systems with a negative response.

Some payers have expressed concern that the ROS caveat may be over-utilized, especially for visits with lower levels of medical decision making where documentation of a complete ROS is not required.  In addition, some Medicare contractors have proposed variations to the documentation of ROS.  Specifically, some contractors do not accept the statement "all other systems are negative" as sufficient to support a complete ROS.  Members are advised to be familiar with local requirements.

CPT states:  "The review of systems helps define the problem, clarify the differential diagnosis, identify needed testing, or serves as baseline data on other systems that might be affected by any possible management options."  Given the absence of continuity of care for patients in an emergency department setting, the ROS obtained may be more extensive than other clinical settings.  A reasonably thorough ROS will help guide the evaluation and management of the patient.

Exam: documentation may be body area or organ system based, except a comprehensive exam which is based on organ systems only. The extent of documentation will depend on the nature of the presenting problem. Both CMS and CPT use the following definitions:

• Problem focused:a limited examination of the affected body area or organ system.
• Expanded problem focused:a limited examination of the affected body area or organ system and other symptomatic or related organ system(s).
• Detailed:an extended examination of the affected body area(s) and other symptomatic or related organ system(s).
• Comprehensive:a general multi-system examination or a complete examination of a single organ system.

Both CMS and CPT use the descriptions in FAQ 9. Only the comprehensive exam has an official numerical requirement in the 1995 Documentation Guidelines for Evaluation & Management Services, "The medical record for a general multi-system examination should include findings about 8 or more of the 12 organ systems."

Within the coding industry there are recognized numerical values for the exam levels.
• Problem Focused - 1 body area or organ system
• Expanded problem focused - 2-7 body areas or organ systems
• Detailed - 2-7 body areas or organ systems
• Comprehensive - 8 or more organ systems

Most payers that publish their E&M policies or audit sheets indicate that Expanded Problem Focuses and Detailed both encompass 2-7 areas or systems, with the dividing line being the limited vs expanded exam of the affected area. The following are just a few examples taken from MAC websites:
• CGS – Detailed physician exam includes extended exam of the affected body region or organ system.
• NGS – Expanded Problem Focused – 2-7 areas of system (Minimal detail for areas/systems examined; check list documentation without any expansion of documentation findings.
• NGS – Detailed - 2-7 areas of system (Expanded documentation of areas/systems examined; requires more than checklists; needs to have normal/abnormal finding expanded upon.
• Novitas – recognizes the 2-7 areas or systems, but also includes a 4 x 4 method as an alternative. Novitas Evaluation and Management 4 x 4 Method
The CPT/CMS description of Problem Focused exam uses the phrase "examination of the affected body area or organ system" which is interpreted as Problem Focused exam requires 1 body area or organ system be examined.

The official source for this information is the CMS website at www.cms.hhs.gov.  ACEP regularly monitors this site for changes. 

• 1995 Documentation Guidelines
• 1997 Documentation Guidelines

Medical Decision Making and The Marshfield Clinic Scoring Tool

When assigning an Evaluation and Management Level of Service for a patient encounter, significant factors to consider are the Nature of the Presenting Problem (NOPP) and the complexity of Medical Decision Making (MDM). 

As of 2021, CPT has a definition and description of Medical Decision Making (MDM) specific to the E/M Office or Other Outpatient E/M codes 99202-99215.  There is a separate definition and description for MDM that applies to all other categories of E/M codes (Hospital Observation, Hospital Inpatient, Consultations, Emergency Department, Nursing Facility, Domiciliary, Rest Home, or Custodial Care, and Home Services)

For the Office or Other Outpatient E/M codes 99202-99215, MDM includes establishing diagnoses, assessing the status of a condition, and/or selecting a management option. Three elements define MDM in the office or other outpatient services codes:

• The number and complexity of problem(s) that are addressed during the encounter.
• The amount and/or complexity of data to be reviewed and analyzed. These data include medical records, tests, and/or other information that must be obtained, ordered, reviewed, and analyzed for the encounter. This includes information obtained from multiple sources or interprofessional communications that are not reported separately and interpretation of tests that are not reported separately. Ordering a test is included in the category of test result(s) and the review of the test result is part of the encounter and not a subsequent encounter. Ordering a test may include those considered but not selected after shared decision making. For example, a patient may request diagnostic imaging that is not necessary for their condition and discussion of the lack of benefit may be required. Alternatively, a test may normally be performed, but due to the risk for a specific patient it is not ordered. These considerations must be documented. Data are divided into three categories:
  • Tests, documents, orders, or independent historian(s). (Each unique test, order, or document is counted to meet a threshold number.)
  • Independent interpretation of tests.
  • Discussion of management or test interpretation with external physician or other qualified health care professional or appropriate source.
• The risk of complications and/or morbidity or mortality of patient management decisions made at the visit, associated with the patient’s problem(s), the diagnostic procedure(s), treatment(s). This includes the possible management options selected and those considered but not selected, after shared MDM with the patient and/or family.

For all other categories of E/M codes (Hospital Observation, Hospital Inpatient, Consultations, Emergency Department, Nursing Facility, Domiciliary, Rest Home, or Custodial Care, and Home Services), MDM refers to the complexity of establishing a diagnosis and/or selecting a management option as measured by:

1. The number of possible diagnoses and/or the number of management options that must be considered.
2. The amount and/or complexity of medical records, diagnostic tests, and/or other information that must be obtained, reviewed, and analyzed.
3. The risk of significant complications, morbidity, and/or mortality, as well as comorbidities, associated with the patient’s presenting problem(s), the diagnostic procedure(s), and/or the possible management options.

The focus of this FAQ going forward will be Medical Decision Making (MDM) as it relates to the Emergency Department E/M codes 99281-99285. For more information about MDM for the Office or Other Outpatient E/M codes, 99202-99215 see the 2022 E/M Guidelines FAQ

Both sets of MDM guidelines identify the following types of MDM:

• Straightforward
• Low Complexity
• Moderate Complexity
• High Complexity

The CMS Evaluation and Management Services Guide and the 1995 E/M Documentation Guidelines reiterate the same MDM elements as CPT but provide more explanation and examples for each of the elements.

CPT does not offer further explanation of the Number of possible diagnoses and/or the number of management options that must be considered (DMO) other than the following values:

• Minimal
• Limited
• Multiple
• Extensive

The 1995 E/M Documentation Guidelines (DGs) indicate that DMO is based on the number and types of problems addressed during the encounter, the complexity of establishing a diagnosis and the management decisions that are made by the physician. The DGs also state:

• Generally, decision making with respect to a diagnosed problem is easier than that for an identified but undiagnosed problem.
• The number and type of diagnostic tests employed may be an indicator of the number of possible diagnoses. Problems which are improving or resolving are less complex than those which are worsening or failing to change as expected. 
• The need to seek advice from others is another indicator of complexity of diagnostic or management problems.

CPT does not offer further explanation of the amount and/or complexity of medical records, diagnostic tests, and/or other information that must be obtained, reviewed, and analyzed (Data) other than the following values:

• Minimal or None
• Limited
• Moderate
• Extensive

The 1995 E/M Documentation Guidelines (DGs) say the amount and complexity of data to be reviewed is based on the types of diagnostic testing ordered or reviewed.  The DGs also offer:

• A decision to obtain and review old medical records and/or obtain history from sources other than the patient increases the amount and complexity of data to be reviewed.
• Discussion of contradictory or unexpected test results with the physician who performed or interpreted the test is an indication of the complexity of data being reviewed.
• On occasion the physician who ordered a test may personally review the image, tracing or specimen to supplement information from the physician who prepared the test report or interpretation; this is another indication of the complexity of data being reviewed.

CPT does not offer further explanation of the risk of significant complications, morbidity, and/or mortality (Risk) other than the following values:

• Minimal
• Low
• Moderate
• High

The 1995 E/M Documentation Guidelines (DGs) indicate that Risk is based on the risks associated with the presenting problem(s), the diagnostic procedure(s), and the possible management options. The DGs provide the Table of Risk that may help determine the level of the Risk. Regarding the Table of Risk, the DGs state: 

• Because the determination of risk is complex and not readily quantifiable, the table includes common clinical examples rather than absolute measures of risk.
• The assessment of risk of the presenting problem(s) is based on the risk related to the disease process anticipated between the present encounter and the next one.
• The assessment of risk of selecting diagnostic procedures and management options is based on the risk during and immediately following any procedures or treatment.

See the 1995 E/M Documentation Guidelines linked below for the Table of Risk.

Many Medicare Administrative Contractors (MACs), auditors, consultants, and coders use some version of the E/M Documentation Auditors Worksheet that the Marshfield Clinic initially published in 1995. At the time, Marshfield Clinic was a large multi-specialty, primarily office-based practice with 30+ clinics throughout Wisconsin.  The CMS E/M Documentation Guidelines were beta-tested at Marshfield Clinic before being released for implementation in 1995.  As part of that process, Clinic staff helped their regional Medicare carrier develop an audit worksheet that included a scoring system that would help someone not involved in the patient encounter assign a value to the MDM based on documentation in the medical record.

The Marshfield method of scoring MDM has never been officially accepted or endorsed by AMA/CPT or CMS.  Unofficially, CMS personnel have recognized the MDM scoring tool’s existence and have indicated that CMS neither encourages nor discourages its use by MACs.  Some MACs and other payers have a version of the E/M Worksheet posted on their website or publish policies related to their interpretation of how to use the worksheet, but it is not an official CPT or CMS policy.  

The Marshfield Worksheet was developed specifically for services provided in an office setting. Unfortunately, this method of calculating MDM does not always apply well to Emergency Department coding. Patients present to the ED with a wide variety of injuries and illnesses ranging from minor to life-threatening. There are also a multitude of diagnostic tests, therapeutic interventions, and other management options available during the ED visit not available in most office settings.  

Considering the Marshfield Worksheet is not part of the CPT or CMS coding policies and due to the discrepancies between MDM complexities in the office setting versus the emergency department, many ED physician organizations have elected to adhere to the descriptions and definitions of MDM from the CPT book, the 1995 E/M Documentation Guidelines and the CMS Evaluation and Management Services Guide to establish internal and/or proprietary policies for assigning value to the complexity of the MDM.

Table A from the Marshfield MDM scoring tool uses the type and severity of the presenting problem(s) to gauge and assign a point value to the number of possible diagnoses and/or the number of management options considered.

Once the points are assigned, the total is converted to CPT/CMS values.

• 1 point = Minimal
• 2 point = Limited
• 3 point = Multiple
• 4 or more points = Extensive

This is different from the CPT definition of New Patient vs. Established Patient.  A new problem is new to the examining Physician/QHP. When queried on the issue Bart McCann, MD, former Executive Medical Director of HCFA (now CMS), stated, “The decision making guidelines were designed to give physicians credit for the complexity of their thought processes. Giving a physician more credit for handling a problem he or she is seeing for the first time, even when that problem has been previously identified or diagnosed, is within the spirit of the guidelines.”

Due to the episodic nature of emergency care, ED Physicians/QHPs don’t maintain an ongoing relationship with their patients.  Therefore most ED patients are considered New Problem (to examiner) even though they may present with a chronic or previously diagnosed condition.

Because the MDM scoring tool has never been adopted or endorsed by AMA/CPT or CMS, there is no official coding policy or regulatory guidance that defines “additional workup planned.”  However, with the understanding that the Marshfield E/M Documentation Auditors Worksheet was developed in and for an office-based practice, we can look to standards of practice in that setting to better recognize what may qualify as additional workup.

When a patient presents to their primary Physician/QHP with a new problem, the Physician/QHP performs a history and physical exam appropriate for the chief complaint. In many cases, this will give the Physician/QHP the information needed to determine a diagnosis and appropriate treatment. In more a complex case, the Physician/QHP may order diagnostic tests; they may have the patient schedule an appointment with a specialist, they may prescribe a preliminary treatment with orders to return for re-evaluation or a variety of other options to get the information needed to establish a diagnosis and determine the appropriate treatment.

If a diagnostic test is ordered during an office-based E/M service, samples for a lab test may be drawn during the encounter, but in many cases, the Physician/QHP will arrange for testing at a lab, or the patient will be sent for x-rays, CT, MRI, etc. at a radiology center or outpatient department at a hospital.  If consultation with a specialist is needed, that appointment will be arranged and scheduled for a later date. In both scenarios, the patient is scheduled for a return office visit to review the test results and/or consultation and discuss treatment options during a second E/M service.  In an office-based practice the MDM for these encounters would be scored as “additional workup planned.”  

In the Emergency Department, comprehensive diagnostic testing (lab tests, x-rays, CTs, MRIs, ultrasounds, etc.) is readily available to the patient during the ED encounter. The ED Physician/QHP can request and receive a consultation from a specialist while the patient is in the ED. The patient can undergo a preliminary treatment regimen and be re-evaluated during the same encounter.  The fact that this level of diagnostic and therapeutic intervention is provided during a single E/M encounter does not discount the severity or complexity of the “The number of possible diagnoses and/or the number of management options that must be considered.”

In cases where the ED Physician/QHP has efficiently assessed the number of possible diagnoses and/or the number of management options using the diagnostic and therapeutic interventions available to them, it seems reasonable to recognize the complexity of this process as “additional workup planned” when assigning value for this component of the MDM.

Again, the MDM scoring is not part of the official coding policy from CPT or CMS, so there isn’t any guidance on determining what qualifies as Additional Workup Planned. The MDM scoring for DMO is trying to establish when Minimal, Limited, Multiple or Extensive diagnoses or management options are considered. 

ED physician practices and their coders should determine what type or how many ancillary tests, consultations, etc., accurately indicate when there has been an extensive number of diagnosis or management options considered.  It may not be appropriate to assign an extensive number of diagnosis or management options for a patient that solely received a single simple test such as a strep test for a sore throat or a single x-ray for an ankle injury. Conversely, when a patient has labs and ultrasound for abdominal pain or an EKG and bloodwork for chest pain, it seems suitable that this level of diagnostic work indicates an extensive number of diagnosis or management options.

Table B from the Marshfield MDM scoring tool assigns points to the different diagnostic tests and other data elements that can be obtained, reviewed, and analyzed during the E/M encounter.

Once the points are assigned, the total is converted to CPT/CMS values.

• 1 point = Minimal or None
• 2 point = Limited
• 3 point = Moderate
• 4 or more points = Extensive

No, as of 2021, the Marshfield scoring's current interpretation is 1 data point assigned per test. Only ordering the test, only reviewing the test, or doing both is only 1 point.

Table B recognizes how the need to obtain further information to accurately diagnose and treat the patient increases medical decision-making complexity. Two thought processes receive credit for old records and/or obtaining a history from someone other than the patient.  The first is the decision that additional information is needed.  That decision is scored with 1 point.  The second part of the process is reviewing information obtained and using it in the decision making process. That thought process is scored with 2 points. 

Appropriate documentation is necessary to score the additional 2 points, per the 1995 E/M DGs “Relevant finding from the review of old records, and/or the receipt of additional history from the family, caretaker or other source should be documented. If there is no relevant information beyond that already obtained, that fact should be documented.  A notation of “Old records reviewed” or “additional history obtained from family” without elaboration is insufficient.”  

CPT defines another healthcare provider as “An external physician or other qualified health care professional who is not in the same group practice or is of a different specialty or subspecialty. This includes licensed professionals who are practicing independently. The individual may also be a facility or organizational provider such as from a hospital, nursing facility, or home health care agency.”

No, only 2 points are counted for any or all of the elements in that row of Table B.

The physician/QHP must personally look at the image, tracing or specimen, not simply review the written report from another provider.  The physicians/QHPs visualization should be documented but does not need to meet the standards of a report prepared by a specialist or satisfy the requirements for assigning the CPT code for interpretation.

No, per CPT, “for the purposes of data reviewed and analyzed, pulse oximetry is not a test.”

There are 3 data points that could be assigned to each ECG or X-ray.  One point is assigned for ordering the study and/or reviewing the results. An additional two points can be added when the Physician/QHP has documented their independent visualization of the image or tracing. For a total of 3 data points, when the ECG or X-ray is interpreted by the ED physician/QHP.

Historically, the 2 data points for the independent visualization were a way to show the additional mental effort associated with establishing a diagnosis and/or selecting a management option based on the Physician’s/QHP’s own interpretation of an ECG or x‐ray. The 2 points for the interpretation were not intended to replace the reimbursement for performing and documenting an interpretation. 

However,  CPT has modified their explanation of Services Reported Separately under the heading “Guidelines Common to All E/M Services”. CPT 2022 states:

“The ordering and actual performance and/or interpretation of diagnostic tests/studies during a patient encounter are not included in determining the levels of E/M services when the professional interpretation of those tests/studies is reported separately by the physician or other qualified health care professional reporting the E/M service.” 

Also included in the same section CPT “If a test/study is independently interpreted in order to manage the patient as part of the E/M service, but is not separately reported, it is part of MDM.”

With the revision to the CPT language, you cannot report the CPT code for the interpretation and count the data points toward the MDM scoring.

Individual payers could have scoring grids that may or may not incorporate this new language. In particular, concerning Medicare, the ED E/M codes are still bound by the 1995 Documentation Guidelines and various Medicare Administrative Carriers published policies. This evolving area should be cleared up for dates of service beginning January 1st,  2023, when revised ED E/M Documentation Guidelines are likely.

The Table of Risk used in the Marshfield method of scoring MDM is the only part of the scoring method pulled directly from the 1995 E/M Documentation Guidelines.  The Table of Risk uses the presenting problem(s), the diagnostic procedure(s) ordered, and management options selected to determine if the risk of significant complications, morbidity, and/or mortality is Minimal, Low, Moderate or High with the highest level of risk in any one category (presenting problem(s), diagnostic procedure(s), or management options) determining the overall risk.

As an example, when a patient presents with an injury, the coder is relying on the documentation to determine if it is an acute uncomplicated injury (low risk), an acute complicated injury (moderate risk) or an injury that poses a threat to life or bodily function (high risk).   Clear documentation of the patient’s chief complaint, associated signs and symptoms, differential diagnoses or “possible,” “probable,” or “rule out” diagnoses and final diagnosis will help the coder make the correct determination.  Furthermore, diagnostic and therapeutic interventions also contribute to understanding the risk of the presenting problem.

In addition, the 1995 E/M DGs state:

• For each encounter, an assessment, clinical impression, or diagnosis should be documented. It may be explicitly stated or implied in documented decisions regarding management plans and/or further evaluation.
• Comorbidities/underlying diseases or other factors that increase the complexity of medical decision making by increasing the risk of complications, morbidity, and/or mortality should be documented.

The risk for selecting a diagnostic procedure is based on the risk during and immediately following the procedures. For example, on the Risk Table, x-rays EKG, Urinalysis and Ultrasound are in the minimal risk category.  Meaning there is minimal risk the diagnostic procedure will cause significant complications, morbidity, and/or mortality to the patient.  A patient with a presenting problem that requires an EKG or Ultrasound will likely be considered high risk in the presenting problem column.

Treatment rendered in the ED, orders given at discharge, procedures ordered, planned, scheduled or performed, medications given in the ED, prescriptions written, follow-up appointments, etc., are all factors in assessing the risk based on management options selected.

The classification of surgery into minor or major is based on the common meaning of such terms used by trained clinicians. These terms are not defined by a surgical package classification.

Elective procedures and emergent procedures describe the timing of a procedure when the timing is related to the patient’s condition. An elective procedure is typically planned in advance (e.g., scheduled for weeks later), while an emergent procedure is typically performed immediately or with minimal delay to allow for patient stabilization. Both elective and emergent procedures may be minor or major procedures.

See the 1995 E/M Documentation Guidelines linked below for the Table of Risk.