HI255 Unit 8 Evaluation and Management Case Example

Moderate on Two of Three: A Unit 8 Evaluation and Management Case Scoring One Established Office Visit by Medical Decision Making and Finding Support for One Level Below the Level Billed

[Student Name]

Purdue University Global

HI255: Medical Coding II

Unit 8 Evaluation and Management Case

[Instructor Name]

[Date]

The patient, practice and progress note are composite; the office visit guidelines, policy documents and sources cited are real.

The Framework Applied

For office visits billed from 2021 onward, the level rests either on the physician's decision making or on the physician's total time spent that same day. History and examination must be documented as medically appropriate, but they no longer set the level (American Medical Association, 2025). Decision making is judged on three things: which problems the physician dealt with and how serious they were, what results, records and tests the physician looked at or ordered, and how risky the treatment choices were. Any two of those three reaching a level is enough to give the visit that level (Medicare Learning Network, 2024).

The Note in Brief

A composite 58-year-old man with hypertension, on lisinopril and amlodipine, brings a home log showing morning readings between 152 and 164 systolic over the last month. He also has two weeks of sneezing, itchy eyes and a clear runny nose that started when the trees began to bloom. The physician reviewed his basic metabolic panel from last month and a lipid panel from the spring, ordered a urine albumin to creatinine ratio, increased amlodipine from 5 mg to 10 mg, and advised an over the counter nasal steroid spray. Follow-up was set for four weeks. No total time is recorded.

Scoring Grid

1. Problems addressed. Evidence: hypertension not at goal despite two medicines, which is a chronic illness with exacerbation or progression; seasonal allergic rhinitis, an acute uncomplicated illness. Level reached: moderate, because one chronic illness that is progressing meets moderate on its own. It stops short of high, which needs a long-term illness that has worsened severely or a problem that threatens life or bodily function.

2. Data reviewed and analyzed. Evidence: review of the result of each unique test, two items, and ordering a unique test, one item. Level reached: moderate, because three items in the first category meet it. It stops short of extensive, which would need a second category, such as an independent reading of a tracing or a discussion of management with an outside physician.

3. Risk of patient management. Evidence: prescription drug management, a dose change of amlodipine. Level reached: moderate. It stops short of high, which would need something like a decision about hospitalization or drug therapy needing intensive monitoring for toxicity.

All three elements land on moderate. For the billed level to hold, two of them would have had to reach high, and none of them comes close.

Verdict

With problems, data and risk all at moderate, the visit meets moderate complexity medical decision making, which supports the established patient office visit at the fourth level. The fifth level, which was billed, requires high complexity in two of the three elements.

What the History and Examination Add

The note carries a full review of systems and a detailed examination of the heart, lungs, nose and eyes. Under the older rules, that much history and examination would have pushed the level up. Under the current framework it earns nothing toward the level, though it still matters: the examination of the nose and eyes is what supports the allergy diagnosis, and the blood pressure taken twice in the office is part of what shows the hypertension is not at goal. A coder who counts bullet points from the examination is applying rules that no longer govern office visits, and a grader will notice. The same is true of the medication list and the social history. They belong in the note because they are clinically appropriate, and they help a reader understand the dose change, but they do not change the level. The scoring above uses only what the physician addressed, reviewed, ordered and decided.

The Time Route

An office visit can also be leveled by total time, which counts the physician's time on the date of the encounter, including reviewing results, examining, counseling and documenting. The fifth level for an established patient requires at least 40 minutes. The note records no total time, so time cannot support the higher level. If the physician had spent and recorded 40 minutes on that date, the higher level would have been supported by time even with moderate decision making.

A Note on Level Inflation

The difference between the two top levels is a meaningful part of a primary care practice's revenue, and payers watch the share of visits billed at the highest level. Research on hospitals adopting electronic records found no clear evidence that the systems drove up billing intensity, but the concern about templates that make every note look complex has not gone away (Adler-Milstein & Jha, 2014). The answer here is not an accusation. It is to code from the decision making the note describes and, where physicians want time credited, to ask that total time be documented.

References

Adler-Milstein, J., & Jha, A. K. (2014). No evidence found that hospitals are using new electronic health records to increase Medicare reimbursements. Health Affairs, 33(7), 1271-1277. https://doi.org/10.1377/hlthaff.2014.0023

American Medical Association. (2025). CPT 2026 professional edition. American Medical Association.

Medicare Learning Network. (2024). Evaluation and management services guide (MLN006764). Centers for Medicare & Medicaid Services.