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ED Coding and Reimbursement Alert

Inspect Documentation for Clues to MDM

Published on Sat Jan 17, 2004

Decision-making isn't based on the diagnosis alone

Every patient with a head injury doesn't warrant a level-five evaluation and management (E/M) code - so when the physician's documentation hits your desk, make sure you know how to pick the right level of medical decision-making (MDM).
 
The documentation you need to make the distinction between various levels of MDM isn't always readily available. Not only do you need to know what to look for, but you also need to know when to ask the physician for further clarification.
 
While each of the E/M service levels has minimum requirements, your assignment of those levels calls for more than just adding up elements of the physical exam and history. And watch documentation with a critical eye, because just as every head injury doesn't get a level five, a sore throat can have level-five documentation all over it, but may ultimately score as a level three.

Look Closely for All Three Components

1. Number of possible diagnoses or considered management options.
 
Not only should you keep your eyes peeled for the definitive diagnoses, but if a diagnosis is not definitive, make sure your physician has documented pertinent signs and symptoms. If the patient is stable, look for statements telling you whether she has shown improvement or is worsening and whether the doctor has planned a workup. "Most doctors forget to document coexisting or chronic problems that must be considered with the present problem," says Catherine Brink, CMM, CPC, president of Healthcare Resource Management Inc. in Spring Lake, N.J.

2. Amount and/or complexity of data to be reviewed.
 
"Lots of physicians just document 'labs ordered' or 'labs reviewed' but don't spell out specifics," Brink says. So if you see these phrases, be sure to ask for follow-up information. "Also, they forget to document that they reviewed old medical records or consulted with another physician about the problem - this is sometimes common in the ED," she says, where physicians may be pressured with more immediate matters.

3. Risk of significant complications, morbidity and/or mortality, and comorbidities.
 
CPT's Table of Risk governs this element of the MDM process and consists of three parts:

 

  •  Presenting problem, in which the doctor must document whether the patient's condition is stable or  worsening, or whether an undiagnosed new problem occurs (similar to the first element, "number of diagnoses")
     
  •  Diagnostic procedures ordered, in which doctors need to spell out what they are ordering - for example, cardiac stress tests or endoscopies - since these tests can affect the overall risk to the patient
     
  •  Management options selected, in which the physician specifies what treatment she plans for the patient, such as minor surgery, major surgery, or prescriptions.
     
    Remember that the documentation guidelines say you only need two of these three main categories to meet or exceed the level of MDM ultimately assigned to a chart. Of note, the highest level of risk in any one category in the table determines the overall risk.

    Don't Discount Common Sense

    "I tell physicians that a general guideline to MDM is 'What's the overall risk to the patient's morbidity and mortality,' " Brink says. For example, if a patient has a cold that just requires over-the-counter medication and not prescription drugs, there is minimal risk to the patient's morbidity. But if a patient presents with bronchitis, and receives prescription drugs and a chest x-ray to rule out pneumonia, then moderate to high risk is present. "A patient who presents to the ED with severe chest pain and  sweating - symptoms of a heart attack - is probably high-risk, since the condition could be life-threatening," Brink says.

    Ask for the Unsaid With Documentation

    You know the crux of assigning codes hinges on documentation, but dissecting a doctor's description into the components of E/M service levels requires some knowledge of what the medical treatment entails. The code isn't just about patient history and review of systems.
     
    For example, if a physician prescribes two or three medications, talks to a consultant, and reevaluates the patient twice, the case might warrant a level four or five, depending on the risk to the patient and the kind of tests performed. Your key to success here is to make sure the physician documents the case's complexity - not just the diagnosis and procedures.
     
    "Documentation is the key," Brink says. "If doctors don't write down all diagnoses, tests and labs ordered or reviewed, records reviewed, whether they consulted other physicians, and don't document a good plan of care," she says, "then their MDM will probably not convey what they actually did and could bring down the overall level of E/M - especially with ED services, since all three elements (history, examination, and medical decision- making) are necessary to determine level of service."
     
    The most prevalent coding error involving medical decision-making is failure to code every facet of the patient encounter, and the fault usually lies with the physician rather than the coder. Without knowing exactly what happened, even the most objective and conscientious coder can't have the complete picture.

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