E/M coding scenario: Suspected MS meets a level 5 established office visit

Why This Topic Matters

The article offers context for clinicians and coding professionals reviewing how E/M service-level assessment may involve medical decision-making, time, and guidance from different authorities.

Article Sections

1. History of Present Illness

   Covers the patient's reported history and the development of neurological symptoms over time.

2. Past Medical History

   Summarizes relevant background medical history.

3. Allergies

   Notes the patient's reported allergies.

4. Social History

   Covers selected social and lifestyle information.

5. Past Surgical History

   Summarizes the patient's surgical history and general health background.

6. Review of Outside Radiological Studies

   Reviews imaging records considered during the neurological evaluation.

7. Physical Exam

   Presents general examination findings from the encounter.

8. Neurological Exam

   Covers findings from the neurological examination.

9. Diagnostic Impression

   States the diagnostic framing documented for the case.

10. Case Discussion

    Discusses the clinical case and broad management considerations.

11. Time spent

    Identifies the time component documented for the encounter.

12. Choose the correct code

    Introduces the coding analysis for the established office visit.

13. Number and complexity of problems addressed

    Addresses the problem-complexity element considered in the MDM discussion.

14. Amount and/or complexity of data to be reviewed and analyzed

    Covers the data-review element considered in the MDM discussion.

15. Risk of complications and/or morbidity or mortality of patient management

    Addresses the risk element considered in the MDM discussion.

16. Level of MDM based on 2 out of 3 elements of MDM

    Summarizes the article's MDM assessment framework for the scenario.

17. Code selection

    Presents the article's time-based coding discussion and references to CPT and CMS guidance.

18. Rationale

    Provides the article's rationale section for its coding discussion.

19. Bonus Tip

    Offers an additional note about E/M service-level assessment.