5 Types of Presenting Problems Let me outline the five types of

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5 Types of Presenting Problems
Let me outline the five types of presenting problem described in the CPT book.
Minimal: A problem that might not require the presence of the physician, but service is provided under the physician's
supervision.
Self-limited or minor: A problem that runs a definite and prescribed course, is transient in nature and is not likely to
permanently alter health status or that has a good prognosis with management and compliance.
Low severity: A problem where there is little to no risk of mortality without treatment; full recovery without functional
impairment is expected.
Moderate severity: A problem where there is moderate risk of mortality without treatment, an uncertain prognosis or
increased probability of prolonged functional impairment.
High severity: A problem where there is a moderate to high risk of mortality without treatment or high probability of
severe, prolonged functional impairment.
To help make sense of these five types of presenting problem, the CPT book includes a fairly exhaustive list of
clinical examples in Appendix C. An interesting exercise is to look at the code you use most often and read the
clinical examples associated with it. You'll find that the patients in the 99213-level examples often are stable and are
being seen for routine follow-up visits or minor new problems. In the 99214-level examples, patients are being seen
for new problems or exacerbations to existing conditions. They often need new tests, medications or interventions.
Examples of low complexity decision making:

New patient evaluation and management of a 55 year old female who presented for painless gross
hematuria. UA with urine culture was done and cystoscopy was scheduled.
# diagnoses or treatment options – extensive (new prob, add’l w/u planned )
complexity of data - limited (lab, cystoscopy)
risk of complication – low (acute uncomplicated illness)
o

Overall complexity of decision making: low complexity
Office visit for a 60 year old established patient, with chronic essential hypertension on multiple drug
regimen, for blood pressure check.
# diagnoses or treatment options – limited (established problems, stable )
complexity of data - minimal (none)
risk of complication – low (stable chronic illness)
o
Overall complexity of decision making: low complexity
Examples of moderate complexity decision making:

Initial hospital visit for a 61 year old male with history of previous myocardial infarction, who now
complains of chest pain. Lab, CXR, and EKG done. Medications were adjusted.
# diagnoses or treatment options – extensive (new problem, additional work up planned)
complexity of data - multiple (lab, radiology, EKG)
risk of complication – moderate (chronic illness with mild exacerbation/ progression, prescription drug
management)
o

Overall complexity of decision making: moderate complexity
Initial hospital consultation for a 33 year old female, post-abdominal surgery, who now has a
fever. Lab, abdominal CT were ordered and antibiotics were prescribed.
# diagnoses or treatment options – extensive (new problem, additional work up planned)
complexity of data - limited (lab, radiology)
risk of complication – moderate (acute illness w/systemic symptoms, prescription drug management)
o

Overall complexity of decision making: moderate complexity
Initial office visit for a 60 year old male with chest pain on exertion. Lab, radiology, EKG and echo
done; medications prescribed.
# diagnoses or treatment options – extensive (new problem, additional work up planned)
complexity of data - multiple (lab, radiology, EKG/echo)
risk of complication – moderate (prescription drug management)
o

Overall complexity of decision making: moderate complexity
Patient has well-controlled diabetes and sub-optimally controlled hypertension. You increase lisinopril from
20 to 40 mg po qd. This visit contains three problem points: two for hypertension (established problem,
worsening) and one for diabetes (established problem, stable). The risk qualifies as moderate due to either
two stable chronic illnesses or prescription drug management.

Otherwise healthy established patient complains of intermittent light-headedness. You perform an ECG and
review the tracing, which is normal. You order a Holter monitor and schedule the patient for a follow-up visit
in one week. This visit contains four problem points for a new problem with additional work-up planned and
three data points (two for independent review of image, tracing or specimen, and one for ordering a medical
test). The risk is moderate based on the presence of an undiagnosed new problem with uncertain prognosis.

Patient has diabetic nephropathy and chronic renal insufficiency, with creatinine stable at 1.5 mg/dL.
Diabetes and blood pressure are both optimally controlled. Labs show that the microalbumin-to-creatinine
ratio has gone from 140 to 320 mg/g. You increase the patient's ARB dose and plan to recheck the renal
profile and spot urine protein in three months. This visit contains three problem points (one each for
diabetes, hypertension and renal insufficiency) and one data point for reviewing labs. The risk is moderate
due to prescription drug management.
Examples of High Complexity Medical Decision Making:

Any new problem with additional workup requiring review of labs and radiology reports, ordering of new
tests, ECG interpretation, and the decision to obtain information from other sources (for example, a patient's
family or old records)

A COPD exacerbation and uncontrolled hypertension

A severe pneumonia with workup

Acute renal failure with workup

Worsening severe chronic kidney disease and uncontrolled hypertension

Stable severe chronic kidney disease, stable diabetes, but uncontrolled proteinuria

Stable severe chronic kidney disease, controlled hypertension, controlled diabetes, controlled proteinuria

Mental status changes with workup

Cardiac catheterization with "risk factors" for chest pain

Endoscopy for GI bleeding

Pain with workup requiring IV narcotics

Therapy with heparin, warfarin, gentamicin, or other medications requiring monitoring for toxicity and any
new problem with workup

Withdrawing care or signing a DNR because of poor prognosis

Any "major surgery" with "risk factors"

Any emergency "major surgery"
# diagnoses or treatment options – extensive (new problem, additional work up planned)
complexity of data - multiple (lab, radiology, EKG/echo)
risk of complication – moderate (prescription drug management)
o
Overall complexity of decision making: moderate complexity
Examples of high complexity decision making:

Office visit with 30 year old male, established patient, for three month history of fatigue, weight
loss, intermittent fever, and presenting with diffuse adenopathy and splenomegaly. Lab, CT
ordered; biopsy scheduled; discussed case with oncologist.
# diagnoses or treatment options – extensive (new problem, additional work up planned)
complexity of data - extensive (lab, radiology, biopsy, discussion w/other provider)
risk of complication – moderate (undiagnosed problem with uncertain prognosis)
o

Overall complexity of decision making: high complexity
Initial hospital visit for a 65 year old male who presents with acute myocardial infarction, oliguria,
hypotension, and altered state of consciousness. Lab, CXR, EKG and echo done.
# diagnoses or treatment options – extensive (new problems, additional work up planned)
complexity of data - multiple (lab, radiology, EKG/echo)
risk of complication – high (acute illness that may pose a threat to life/bodily function)
o

Overall complexity of decision making: high complexity
Subsequent hospital visit for a 55 year old male with severe chronic obstructive pulmonary
disease and bronchospasm; initially admitted for acute respiratory distress requiring ventilatory
support in the ICU but was stabilized, extubated, and transferred to the floor. Now has developed
acute fever, dyspnea, left lower lobe rhonchi and laboratory evidence of carbon dioxide retention
and hypoxemia. Lab, CXR, ABG’s done; discussed with pulmonary medicine; ordered
medications.
# diagnoses or treatment options – extensive (established problems, worsening + new problems)
complexity of data - extensive (lab, radiology, discussion w/other provider)
risk of complication – high (chronic illness with severe exacerbation, acute illness that may pose a threat
to life/bodily function)
o

Overall complexity of decision making: high complexity
Office consultation for 58 year old man with a history of MI and CHF who complains of the recent
onset of rest angina and shortness or breath. The patient has a systolic blood pressure of 90
mmHg and is in Class IV heart failure. Lab, CXR, EKG and echo done; records reviewed. Meds
prescribed.
# diagnoses or treatment options – extensive (new problems, add’l w/u planned)
complexity of data - extensive (lab, radiology, EKG/echo, review of records)
risk of complication – high (chronic illness with severe exacerbation)
o

Overall complexity of decision making: high complexity
Initial inpatient consultation for 76 year old female with massive, life-threatening gastrointestinal
hemorrhage and chest pain. Lab, diagnostic imaging, EKG performed, blood transfusion given,
discussed with surgeon.
# diagnoses or treatment options – extensive (new problems, add’l w/u planned)
complexity of data - extensive (lab, radiology, EKG, discuss with other provider)
risk of complication – high (acute illness that may pose a threat to life/bodily function)
o
Overall complexity of decision making: high complexity
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