EM Coding Alert

Get down to the nitty gritty of the MDM elements.

Last month, we looked at advice Angela Clements, CPC, CPMA, CEMC, CGSC, COSC, CCS, AAPC Approved Instructor, physician coding auditor/educator consultant for medKoder in Mandeville, Louisiana, provided regarding coding office/outpatient evaluation and management (E/M) services by time.

This month, we turn our attention to coding the same services using medical decision making (MDM) and some key problems Clements noted you can encounter documenting the three MDM elements — the number and complexity of problem(s) addressed during the encounter, the amount and/or complexity of data reviewed and analyzed, and the risk of complications and/or morbidity or mortality of patient management.

Here are some of the nuances of MDM coding as Clements outlined them in her Regional HEALTHCON 2024 presentation, “E/M Coding: An Auditor’s Perspective.”

Only Count Problems Treated on DOS

“The AMA clearly tells us that a problem addressed is something impacting that encounter on that date of service [DOS],” Clements observed. “What I try to remind my providers is, because we’re not coding for those diagnosis codes, or we’re not using them to level the service, it doesn’t mean the patient doesn’t have that condition. It just means it didn’t impact your visit on that date.”

For example, suppose a patient comes in to be treated for acute sinusitis at the end of a month after being seen earlier in that month for their chronic conditions. In this situation, you will not be able to use the chronic conditions to level the service. The only thing that can be used to level the service on this particular DOS is the acute sinusitis.

However, suppose the patient needs steroids to help treat the infection, and one of the patient’s chronic conditions is diabetes. As steroids can change a patient’s blood sugar levels, the provider may order and interpret the results of an A1C to determine if it is safe to treat the patient this way. The diabetes now becomes significant in the encounter, Clements observed, and if the provider documents the diabetes for the encounter, this makes the connection to the E/M service and will impact the MDM for the encounter.

Always Use Adjectives When Documenting Problem Status

Clements also offered a reminder to providers to “use your adjectives.” So often, providers simply list patient’s conditions in the assessment plan without providing the status of each condition at the time of the encounter. So, a chronic condition being treated that is stable at the time of the encounter only rises to a low level of MDM. However, a chronic illness “with exacerbation, progression, or side effects of treatment,” per CPT^® guidelines, rises to the moderate level of MDM, while that same condition with a severe exacerbation, progression, or side effect of treatment rises to a high level of MDM.

Defer to Definitions to Determine Data Element

Clements then clarified the following definitions that come into play when reviewing the data element for MDM:

• “Unique test” means a test that is defined by a CPT^® code.
• “External” means outside of your practice; by extension, “external physician” means not of the same group practice specialty or subspecialty.
• “Independent historian” means parent, guardian, surrogate, spouse, or witness. This does not include a translator, who is merely relaying information and not providing it.
• “Appropriate source” means a lawyer, parole officer, case manager, teacher, and so on “who are not health care professionals but may be involved in the management of the patient” per CPT^® guidelines. (Note: a hospital social worker would be regarded as a healthcare professional in this instance, and so would not qualify).

Unlike the other MDM elements, the data element is comprised of different categories, and level calculations are dependent on satisfying the number of categories as stipulated by the specific level. So, at the moderate data level of MDM, you must satisfy one of the three categories, while you must achieve two of the three before the E/M service rises to the highest level.

Clements also offered the reminder that “the AMA tells you that when you order a test, you get credit at the time you order it, and you have to review it, so you do not get credit for the review at the subsequent visit.” However, you can get credit for reviews performed on tests ordered by another provider, such as a review of tests performed on a patient in urgent care and sent to your provider, and tests ordered between patient visits that are reviewed at a subsequent patient visit.

Remember These Risk Element Rules

Clements also discussed several risk element areas that continue to be problematic. First, she clarified that social determinants of health (SDOH), one of the elements of risk at the moderate level, must correlate with the patient’s condition, and the documentation must show how that SDOH impacts the patient’s care. So, a patient may be struggling financially, but unless that situation affects treatment (the patient cannot afford a certain medication, for example), the SDOH cannot be counted toward the encounter level.

Next, Clements noted that you can count over-the-counter (OTC) medication at the low level of risk with the understanding that OTC medication is not automatically a low-level risk for every patient. Meanwhile, at the high level of risk MDM, drug therapy requiring intensive monitoring for toxicity must be documented as such. In other words, you cannot count monitoring for therapeutic purposes to arrive at this level of MDM, which means you must document the results of lab, imaging, or physiological tests that show the provider is monitoring the toxicity level of the drug being administered.

Additionally, documentation for parenteral (administered into the body intramuscularly, intravenously, or subcutaneously and not through the gastrointestinal tract) controlled substances must go beyond simply listing the drug administered. The risk level must be calculated “based on the usual behavior and thought process of a physician or other qualified healthcare professional in the same specialty or subspecialty” and documented accordingly, according to Clements.

Putting the Elements Together

Simply put, two of the three elements have to be satisfied at the same level in order to support that level of service. But to achieve even the lowest level of E/M, “some kind of patient management has to be going on,” stressed Clements. And if time supports an E/M level that is higher than a level supported by MDM, you can — and should — bill the E/M level based on time rather than MDM.

Bruce Pegg, BA, MA, CPC, CFPC, Managing Editor, AAPC