Understanding the Complexities of Each Defined Condition & How to Document

Number and Complexity of Problems Addressed at the Encounter

December 22, 2020

One element in the level of code selection for an office or other outpatient service is the
number and complexity of the problems that are addressed at an encounter. Multiple new
or established conditions may be addressed at the same time and may affect medical
decision making. Symptoms may cluster around a specific diagnosis and each symptom
is not necessarily a unique condition. Comorbidities/underlying diseases, in and of
themselves, are not considered in selecting a level of E/M services unless they are
addressed and their presence increases the amount and/or complexity of data to be
reviewed and analyzed or the risk of complications and/or morbidity or mortality of
patient management. The final diagnosis for a condition does not in itself determine the
complexity or risk, as extensive evaluation may be required to reach the conclusion that
the signs or symptoms do not represent a highly morbid condition. Multiple problems of
a lower severity may, in the aggregate, create higher risk due to interaction.
Definitions for the elements of medical decision making for office or other outpatient
services are (see Table 2 Levels of Medical Decision Making):
Problem: A problem is a disease, condition, illness, injury, symptom, sign, finding,
complaint, or other matter addressed at the encounter, with or without a diagnosis being
established at the time of the encounter.
Problem addressed: A problem is addressed or managed when it is evaluated or treated
at the encounter by the physician or other qualified health care professional reporting the
service. This includes consideration of further testing or treatment that may not be elected
by virtue of risk/benefit analysis or patient/parent/guardian/surrogate choice. Notation in
the patient’s medical record that another professional is managing the problem without
additional assessment or care coordination documented does not qualify as being
‘addressed’ or managed by the physician or other qualified health care professional
reporting the service. Referral without evaluation (by history, exam, or diagnostic
study[ies]) or consideration of treatment does not qualify as being addressed or managed
by the physician or other qualified health care professional reporting the service.
Minimal problem: A problem that may not require the presence of the physician or other
qualified health care professional, but the service is provided under the physician’s or
other qualified health care professional’s supervision (see 99211).

 

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