# Mdm - role in my E/M leveling



## LTibbetts (Apr 29, 2011)

I have heard from an auditor at a local consulting firm that very soon in the future, auditors will be focusing more on the first column of the MDM table of risk vs. the second and third columns. Has anyone out there heard anything about this? I code the ER so my problem points are always at least 3 or higher, being that everyone is a new patient so every problem is a new problem, so the table of risk plays a very big role in my E/M leveling. Very often in the ER we get patients that are given or prescribed meds, which puts you in a moderate risk level, in column three, but it doesn't always match up with column one, so I was just wondering if anyone out there had heard anything about this or may know more about it. I have always been consistent about the way that I level E/M's so this may very well change my leveling process so I just wanted some sort of back-up or confirmation before I change the way I do this. I would very much appreciate any input that you can share. 
Thanks


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## btadlock1 (Apr 29, 2011)

LTibbetts said:


> I have heard from an auditor at a local consulting firm that very soon in the future, auditors will be focusing more on the first column of the MDM table of risk vs. the second and third columns. Has anyone out there heard anything about this? I code the ER so my problem points are always at least 3 or higher, being that everyone is a new patient so every problem is a new problem, so the table of risk plays a very big role in my E/M leveling. Very often in the ER we get patients that are given or prescribed meds, which puts you in a moderate risk level, in column three, but it doesn't always match up with column one, so I was just wondering if anyone out there had heard anything about this or may know more about it. I have always been consistent about the way that I level E/M's so this may very well change my leveling process so I just wanted some sort of back-up or confirmation before I change the way I do this. I would very much appreciate any input that you can share.
> Thanks



I think what they might have meant by that, is that when taking the nature of the presenting problem into account, the first column of the risk table is the best gauge of the severity of the patient's issue; sometimes the points system for MDM produces inflated results - you can take a very simple problem, and be able to do enough work up to technically support a moderate to high MDM, even if the problem doesn't really warrant that much effort. Prescribing an antibiotic will automatically boost your risk to moderate, since you select the highest level obtained on the table. It's not so much that they're telling you to change the way you select the risk level - which is outlined in documentation guidelines; it's that they're letting you know that just because your MDM may have scored something such as moderate or high, doesn't necessarily mean that your visit won't be downcoded to what it_ would _have scored if the amount of work documented had been proportionate to the usual amount of work done for that problem, which can only be determined by assessing the risk associated with the chief complaint (in other words, the criteria in the first column of the Table of Risk). 

Did I just make that more confusing? Sorry...
Think of the first column as having executive control over the code selection - it can't make the visit worth more than the documentation supports, but it can essentially veto an unjustified high level selection, based on lack of medical necessity. I hope that helps!


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## m.j.kummer (Apr 29, 2011)

As far as I am aware, Trailblazer is the only one that has revised the MDM process.  Here is a link to their audit form.
http://www.trailblazerhealth.com/Publications/Job Aid/coding pocket reference.pdf

First Column - meaning problems column (Number of diagnoses or management options)?

Self-limited or minor (maximum of 2)	
Established problem, stable or improving	
Established problem, worsening	
New problem, with no additional work-up planned (maximum of 1)	
New problem, with additional work-up planned	

If it is this column, for the most part would it not fall into one of these for a patient presenting to the ER?
New problem, (to provider) with no additional work-up planned (maximum of 1)	
New problem, (to provider) with additional work-up planned

How does all of this affect ER coding?  

Thanks for sharing.


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## btadlock1 (Apr 29, 2011)

m.j.kummer said:


> As far as I am aware, Trailblazer is the only one that has revised the MDM process.  Here is a link to their audit form.
> http://www.trailblazerhealth.com/Publications/Job Aid/coding pocket reference.pdf
> 
> First Column - meaning problems column (Number of diagnoses or management options)?
> ...



There are 3 parts to MDM, accoring to Trailblazer:
You've got your # of diagnosis/treatment options, Amount/complexity of data reviewed, and risk. The first 2 have values from 1-4 points (corresponding with Straightforward MDM - High), and the third utilizes the Table of Risk, which is sort of a composite grouping of the risks associated with the problem itself, the diagnostic procedures relating to the problem, and the chosen treatment option(s) - the risk is determined to be the highest level of risk in any given column of the table of risk. 

To be completely honest with you, I find Trailblazer's MDM point-system kind of confusing, especially when it comes to the # of diagnoses/treatment options. You have a point tally for the # of diagnoses, and a separate one for the # of treatment options, and you're supposed to use the higher total # of points between the two. I almost always end up using the 'treatment' points, because I'm not sure if I'm allowing the right # of 'diagnosis' points.(See pages 2 & 3 or the audit tool: http://www.e-medtools.com/Aqua_Medicare_Coding_Worksheet.html) 
For example, I'm not sure how many points to give for a patient with 2 distinct complaints, when the diagnosis hasn't been established for one, and the provider is trying to confirm/rule-out 2 or more specific differential diagnoses - and the other complaint is for an established problem with confirmed co-morbidities - it seems like nearly anytime the patient has more than one problem, you could easily go over 4 points. On the flip side of that, as you pointed out - the patient may only have one problem which could be pretty severem which would be hard to score accurately using the points available - I could know that a problem is serious, and it's obvious to me that the diagnostic tests are geared toward determining a specific suspected diagnosis, but unless the doctor lists every possible condition they're theorizing every time, I have absolutely no idea how mnay plausible differential diagnoses there may be for a given set of symptoms - I'm not a doctor. It's much easier to identify the number of treatment options, so I'm more comfortable using that point total. My experience has been that doctors document their management plans within a much closer ratio to the actual severity of the problem, (i.e., 1 point for a minor problem, 2-3 for typical moderate problems, 4 points for a really serious problem). 

The question LTibbets was asking, is in regard to the* table of risk*, in particular. She had heard that instead of selecting the highest level of risk reached as the overall risk level (across all 3 columns), that auditors would mainly focus on the first column, which only pertains to the risk associated with the problem, and they'd give less consideration to the risk levels in the other 2 fields, which I don't think is right - I think the explanation the consultant gave her was misleading, and probably didn't communicate what they were trying to say, in the way they thought it had.

So, before I ramble on too much further - does that clear things up any?


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## LTibbetts (May 4, 2011)

Brandi, thanks so much for your explanation and it made complete sense, by the way...lol! I did notice that somewhere in your response you mentioned that giving the patient antibiotics automatically make the level of risk a moderate, which is where the bulk of my issue with all of this is. We have many strep throats, bronchitis, etc, in the er and they almost always give out meds, so are you saying that you would always charge a level three for these (if the documentation also supports that level)?


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## btadlock1 (May 4, 2011)

LTibbetts said:


> Brandi, thanks so much for your explanation and it made complete sense, by the way...lol! I did notice that somewhere in your response you mentioned that giving the patient antibiotics automatically make the level of risk a moderate, which is where the bulk of my issue with all of this is. We have many strep throats, bronchitis, etc, in the er and they almost always give out meds, so are you saying that you would always charge a level three for these (if the documentation also supports that level)?



Not necessarily - if the # of diagnosis/treatment options and the amount/complexity of data, are straightforward or low, then the risk being moderate doesn't do much to affect the overall MDM. Remember, out of those 3 elements, the level that has at least 2 elements is the overall MDM. (Keep in mind that my MAC is Trailblazer, so I'm used to their audit tool, which assigns 1 - 4 points for the first 2 elements, which corresponds with SF, Low, Moderate, High) If the diagnosis/treatment and/or the data portion(s) score 3 (moderate) or 4 (high), and you have an antibiotic/medication prescribed (moderate risk), then the overall MDM is moderate. 

Does that help?


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## LTibbetts (May 6, 2011)

Definitely....thanks so much!!! As far as the other elements of the MDM, since I do the ER coding, every patient that is seen gets either 3 or 4 points in the # of dx's coulmn, since each patient is new, therefore, each presents with a new problem (except for global visits obviously). Then we can always add other chronic conditions that are also treated. So that should even things out for my level three's, right?


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