The first post in this series outlined how to code most E/M office visits in just two steps:
Now here’s a way to do your documentation that will allow you to quickly determine the visit level for most visits just by looking at a single sentence in your assessment and plan. I call it the Problem/Status/Rx (PSR) format.
|Problem||Status||Rx (prescription management)|
|Hypertension (HTN)||BP elevated||Increase amlodipine|
|Diabetes mellitus (DM)||A1C not to goal||Increase insulin glargine|
|Attention-deficit/hyperactivity disorder (ADHD)||Not improving||Increase lisdexamfetamine|
|Chronic kidney disease||Stable||Continue current medication|
|Coronary artery disease||Controlled||Continue isosorbide mononitrate|
|Depression||Doing well||Taper off sertraline|
Once you’ve described the problem(s) you addressed at the visit, the status (whether the problem is stable or unstable), and your prescription medication management (Rx) in the assessment/plan, you have all the information you need to code most visits. This requires very little text. Here are some examples.
Level 3 examples (one stable chronic Illness + Rx):
Level 4 examples (one unstable or two stable chronic conditions + Rx):
Key things to remember:
Should you document both total time and MDM?
When is it helpful to “double up” and add total time to your note? Even if you are confident that you have performed and correctly documented a level 4 office visit using medical decision making, adding a total time of 30-39 minutes for an established patient and 45-59 minutes for a new patient will make your level 4 ironclad. However, if your time spent falls below those ranges, then there’s no benefit to including it in the note. It can only cause confusion, potentially resulting in an auditor, insurance company, or coder giving you credit for a level 3 visit. In my opinion, it’s only worthwhile to “double up” and add time to your documentation if you’re coding based on time or if your visit level based on time coincides with your visit level based on medical decision making.
Coming up next: Take the quiz to test your E/M coding knowledge.
— Keith W. Millette, MD, FAAFP, RPh
Posted on Dec. 12, 2022
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