2 MDM Examples Show You the Way to a Level-4 E/M

Follow along using our endocrinology-specific Table of Risk

You can arrive at the appropriate E/M level only with proper documentation and a keen understanding of the MDM maze. Test your savvy now.

Here are two examples of medical decision-making (MDM) selection that show how moderate-complexity MDM might translate into a certain level E/M service. Remember, the highest level of risk in any one category (presenting problems, diagnostic procedures, or management options) determines the overall level of risk.

Example #1: A type II, uncontrolled diabetic with early-stage neuropathy (250.62) presents for a routine exam with your endocrinologist. The physician clearly documents the state of the patient's chronic illness with mild progression since the last visit, and his decision to prescribe oral medications. This documentation qualifies the MDM for a moderate level of risk based on the presenting problem and selected management option (see Article 4).

The physician also lists the relevant co-morbidities (such as hypertension, high cholesterol, and obesity) that he considered while making his decision. According to Table 2 in the CPT manual, multiple diagnoses and moderate level of risk qualify the visit for moderate- complexity MDM. The physician also performed a detailed physical examination. You should therefore report 99214 (Office or other outpatient visit for the evaluation and management of an established patient) because a detailed exam and moderate MDM qualify the visit as a level-four service.

Potential loss: If you had underestimated the level of risk because you thought the patient's condition or selected management option was a low-level risk, you might have chosen a level-three code instead - and missed out on about $35 in rightful reimbursement.

Remember: Physicians must also be sure to document "relevant co-morbidities that affect their MDM and plan of care ... in order to achieve a higher level of service appropriately," says Mary I. Falbo, MBA, CPC, president of Millennium Healthcare Consulting Inc. in Lansdale, Pa. For instance, if a patient has diabetes and hypertension, the hypertension and other heart disease co-morbidities can increase the level of risk. Again, as noted above, other co-morbidities you may encounter in endocrinology include high cholesterol, smoking and obesity, Falbo says.

Example #2: A patient presents with an abnormal thyroid screening result (259.9) and hypertension (401.9). The endocrinologist orders lab tests and prescribes a drug to treat the hypertension. These facts clearly qualify the visit for a moderate level of risk. However, the physician does not adequately document the hypertension and the associated plan of care for this relevant co-morbidity. Because the medical record lacks documentation of the multiple diagnoses and management options, you have no choice but to base your MDM on the one presenting problem (abnormal thyroid screening result).

According to Table 2 in the CPT manual, this documentation equates [...]

- Published on 2004-09-23