ED Coding and Reimbursement Alert

Can you count the points on the medical decision-making aspect of your documentation?

Imagine this scenario: The ED physician orders an EKG or chest x-ray, then also reviews the image or tracing. How many data points can you count in the medical decision-making (MDM) portion of your E/M score? Some ED coders will assign one point, others will say you should get two, while still others would count three.

This question is among the many issues that affect coders who code emergency physician charts, since MDM is a crucial part of the equation for the coding ED E/M services. Read on for a lowdown on how to calculate the patient’s MDM.

Look to These Charts for Guidance

The Marshfield Clinic scoring system, which is not officially part of the CMS documentation guidelines, but is used frequently, breaks MDM down into three components: the number of diagnoses or management options to be considered; the amount or complexity of data to be reviewed; and the risk of complications, morbidity, and/or mortality.

The Marshfield scoring system assigns points for the number of diagnoses or management options to be considered and the data reviewed, but uses the risk table from the CMS E/M Documentation Guidelines to assess the level of risk.

The following tables show how you assign the points:

The last component of MDM, the level of risk, is the only one not assigned points in the Marshfield Clinic scoresheet. Instead, the coder assigns a level of risk to the patient’s presenting problems, the diagnostic procedures performed, and the management options chosen by the provider to determine the highest level. The highest level of risk in any one of these three categories determines whether the overall risk is minimal, low, moderate, or high.

(To determine risk, you’ll need to consult a chart such as the one CMS provides at www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/Downloads/eval-mgmt-serv-guide-ICN006764.pdf.)

Putting it all Together

For the next step, the points in each category are translated back to CPT^®/CMS E/M language and the components are combined to determine the overall complexity of the MDM.

Low complexity MDM maps to level two and moderate MDM maps to both levels three and four.

For a given level of MDM complexity, you must meet or exceed the level scored in two out of three areas of Diagnosis or Treatment Options points, data points, and risk. For instance, high MDM complexity requires at least two of the following: four diagnosis or treatment Options points, four data points, and/or a high level of risk, advises Todd Thomas, CPC, CCS-P, president of ERcoder, Inc. in Edmond, Oklahoma.

It is important to remember that the Marshfield Clinic MDM scoring system was created for the office-based practice and since it is used for E/M codes in all specialties of medicine, there are varying interpretations of some of the elements due to the differences in how patients are evaluated differently based on specialty or setting. Your emergency department should have policies in place to specify how your practice applies the MDM scoring system when coding charts. If you are audited, you want to be able to demonstrate that the coding is performed based on a well-structured policy that is based on sound clinical reasoning and is consistent with the industry standard.

Be Careful When Adding Points

For the scenario in the opening paragraph of this article, if the physician orders an EKG or an x-ray, he will collect one point for ordering each test. In some cases, the ED physician may not perform an independent review of the x-ray image if he has timely access to the radiologist’s interpretation, but the ED physician can be credited with an additional two data points if he does perform and document his own interpretation of the x-ray.

For EKGs, the ED physician always performs an independent visualization of the tracing. As long as the interpretation is appropriately documented in the ED chart, the ED physician is given the two additional data points when calculating the MDM.

The purpose of the MDM scoring system is to calculate the complexity of the physicians thought process, for these tests there are multiple thought processes in play and the Marshfield scoring gives credit for all of them. The physician’s decision that he needs to order a diagnostic test has value, and according to Marshfield scoring that value is one point. The physician’s independent visualization of an image, tracing or specimen to help them determine the appropriate treatment or diagnosis for the patient has value, and Marshfield scoring tells us that value is two points. These points do not override or replace each other, Thomas says. If the ED physician orders an EKG or x-ray and then performs and documents his own interpretation, he receives a total of three data points.

ACEP perspective: When asked whether EDs can count “points” toward MDM for reviewing images/tracings when billing for an ECG or x-ray interpretation, the American College of Emergency Physicians said, “On a basic level -- there is the potential for three points…one point is assigned for ordering the study and using the results for patient evaluation/management. Two points are available for the direct visualization of the tracing/film/specimen. It is possible to give credit for the single point assigned for ordering of the study in addition to billing for the interpretation of the test. It is the latter two points that raise some question … The discussion revolves around the fine point of whether the complexity of data to be reviewed is an assessment of service separate from the work of the interpretation of the test. If these are separate, then the two points can be given in addition to billing for the interpretation of the test. …In that there is no specific clarification on this issue and payment policies do differ, you are advised to contact your local carrier for advice.”

One payer’s perspective: “Two points may be given in the Amount and/or Complexity of Data Reviewed when a practitioner independently visualizes an image, tracing or specimen previously or subsequently interpreted by another physician. The medical record documentation must clearly indicate that the physician/qualified NPP personally (independently) visualized and performed the interpretation of the image; tracing or specimen. Credit will not be given if the documentation reveals the practitioner only read/reviewed a report from another physician/qualified NPP,” says Part B payer Novitas Solutions in a Jan. 22, 2019 online Q&A document.