# Help with E/M Medical Decision Making



## jflynn (Nov 10, 2011)

I am having trouble with E/M coding on the medical decision making. I am curently using the Medicare interactive worksheet at the website http://medicare.fcso.com/EM/165590.asp for assistance on leveling. However, I am confused on what all counts on the decision making. If a doctor lists all past/present or active/inactive diagnosis for that patient do you count them ALL in the decision making or do you just count the diagnosis that the doctor is currently treating the patient for???? I don't want to under level or over level. I just need some clarity.......


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## FTessaBartels (Nov 15, 2011)

*What is being treated/considered*

This is one of the big problems I see with the move to EHR .... EVERYTHING (including the kitchen sink) gets included in the Dx list!

You use only the condition(s) being treated, or considered.  What do I mean by "considered."

Let's say a patient sees the doctor for a common cold. This is a self-limiting problem.  HOWEVER ... if the patient happens to have DM2 well controllled, and a history of chronic sinusitis ... these are conditions that the physician will need to consider in diagnosing and treating the cold.  

Let's say a patient comes to the doctor for a sprained wrist. The past problem list includes GERD and allergy to sulfa drugs.   These two conditions have nothing to do with the evaluation and treatment of the sprain.  

When in doubt, you'll have to query the physician. 

Hope that helps.

F Tessa Bartels, CPC, CEMC


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## cjmusser (Nov 17, 2011)

I agree with the previous comment and find that it is very difficult to determine which conditions can be counted at that particular visit if a provider just gives you a list of all the patient's chronic conditions.

When I am educating providers I state that if they are assessing the condition at the visit there needs to be documentation to support (i.e. history relating to that condition) or if the chronic conditons affect or play into the management of the acute condition it should be documented as well.

With EMR providers are listing every condition the patient has had or currently has and so it is harder to determine what is actually being managed or contributes/raises overall risk of the condition(s) actually being assessed during that encounter.  

Education to providers on documenting medical necessity is increasingly important as well as our ability as coders to clinically have some base knowledge and using critical thinking skills.  But as stated - when in doubt query the provider especially when it comes to the medical decision making.  By doing this both you and the provider are able to learn.

Hope that made sense!


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## btadlock1 (Nov 17, 2011)

JF1979 said:


> I am having trouble with E/M coding on the medical decision making. I am curently using the Medicare interactive worksheet at the website http://medicare.fcso.com/EM/165590.asp for assistance on leveling. However, I am confused on what all counts on the decision making. If a doctor lists all past/present or active/inactive diagnosis for that patient do you count them ALL in the decision making or do you just count the diagnosis that the doctor is currently treating the patient for???? I don't want to under level or over level. I just need some clarity.......



I always recommend this:http://www.trailblazerhealth.com/Publications/Job Aid/DocumentingComponentsEOV.pdf

It's really helpful for understanding it, even if you're not in the Trailblazer area. MDM starts on page 13...


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