EM Coding Alert

Take time to break down the complexity of a diagnosis to get proper reimbursements.

Without spot-on medical decision making (MDM) calculation, you won’t end up with the E/M level of service that fits the diagnosis and plan of care work your physician performed. Instead, you’ll either over- or under-code the encounter. 

Adopt a proven MDM calculation process, such as the Marshfield point system that we’ll examine in this article, and feel confident in your MDM choice.

Assign Points to 3 MDM Components

To determine the level of MDM your physician performs during an encounter, you need to review the following three areas: 

1. Number of diagnoses and/or the number of management options
2. Complexity of medical records, diagnostic tests, and/or other data
3. Risk of complications, morbidity, comorbidities, and/or mortality, associated with the patient’s presenting problem(s), the diagnostic procedure(s), and/or the possible management options.

“The medical decision-making component is the hardest to teach the physicians,” says Suzan (Berman) Hauptman, MPM, CPC, CEMC, CEDC, director of coding operations-HIM at Allegheny Health Network in Pittsburgh, Pa. “It is based on a concept of points. It’s hard for clinicians to conceptualize ‘scoring;’ they just want to practice good medicine and provide good care to their patients.”

There are several ways to review these three components, but using a point system such as the Marshfield system breaks down these three components and gives them point values to help you come up with the overall MDM level. Read on to see how it works.

Count Diagnoses and Management Options

First, start with the status of the diagnosis and/or management options documented in the report. Ask yourself what status best fits the diagnosis and/or workup plan and assign the correlating points as follows:

• Self-limited or minor problems — max of 2, counts for 1 point each
• Each established problem/stable or improving — 1 point each
• Each established problem worsening — 2 points each
• New problem, with no additional workup planned — max of 1, counts for 3 points
• Each new problem, with additional workup planned — 4 points each. 

(Keep in mind that the most points awarded is four.)

Remember: Make sure you are only reporting what your provider documents. If she does not state status of the problem as worsening, you cannot just assume it. 

Helpful hint: Additional workup is any additional information the provider plans to obtain in order to help her make a decision about treatment, including lab work, radiology imaging, or tests. 

Add Up the Data Elements

Once you have the diagnosis status, you move on to the complexity of the data. You’re looking at the illustration of tests that your physician ordered and/or reviewed, discussions she had with other physicians, patient history she got from somewhere other than the patient, and notes about any images your physician personally reviewed and interpreted. You’ll assign points as follows, keeping again in mind that the most points achieved is four:

• Review and/or order of clinical lab tests — 1 point total
• Review and/or order of tests in radiology section — 1 point total
• Review and/or order of tests in medicine section — 1 point total
• Discussion of test results with performing physician — 1 point total
• Decision to obtain old records or obtain history from someone other than the patient — 1 point total
• Review and summarization of old records or obtaining history from someone other than patient or discussion of case with another healthcare provider — 2 points total
• Independent visualization of image, tracing, or specimen itself (not simply review of report) — 2 points total.

Pointer: Be aware that if your physician orders and reviews multiple labs, radiology, or medicine tests during one encounter, you will only assign one point for each type for the encounter. For example, the doctor orders a complete blood count (CBC), hematocrit, and basic metabolic panel (BMP). Even though he orders three tests, you can only count one point toward the data elements portion of MDM. 

Also be aware that you cannot count “reviewed old records” written in the notes as a review and summarization of old records. Your physician has to write in the notes what she found in the old records that are pertinent to this encounter. Similarly, when your physician reviews an image, tracing, or specimen and writing only a short statement about the review won’t cut it. Your provider should document her own complete review and interpretation of the service, including her findings or whether the image/test was normal or abnormal and if additional testing is necessary. 

Determine Level of Risk

The last component to assess is the level of risk of complications and/or morbidity/mortality. To do so, you’ll locate the type of presenting problem, data reviewed or ordered, and the management options in the CMS table of risk. Those three subcategories will combine to determine the encounter’s total level of risk. 

Refer to the entire table of risk on either page 15 of the 1995 E/M Guidelines at www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNEdWebGuide/Downloads/95Docguidelines.pdf or on page 47 of the 1997 Guidelines at cms.gov/outreach-and-Education/Medicare-Learning-Network-MLN/MLNEdWebGuide/Downloads/97Docguidelines.pdf.

The highest level from only one of the three categories (not from each category) determines the patient’s risk level: minimal, low, moderate, or high. Keep in mind that not everything is on the table of risk. So think about what the provider is addressing or the test or treatment ordered and how it compares to similar illnesses or treatment options in the table when determining the risk level. 

Key: Tell your physicians to clearly indicate when they’re taking an intermediate step that they don’t believe will solve the patient’s problem. For example, your physician may try antibiotics before a more aggressive treatment. Explaining that he’s trying the more conservative treatment, but that the patient may require a more aggressive approach, can boost the level of risk.

Pull it All Together to Get MDM

Now that you’ve determined the level of risk, you have what you need to determine MDM.

Create a table with the three components of MDM in rows with their four values and circle your values in each row. Create a fourth row with the four types of MDM. 

Draw a vertical line through the circles in each column. The vertical line with two or three circles reaches the MDM. If your lines go through only one circle, use what is circled second from the far left column to reach the MDM.

Don’t miss: You must have two out of the three MDM components score at a particular level in order to assign that level of MDM. “Of these three, in order to score the service, two of the three must be at the same level in order to select a particular level of MDM,” agrees Hauptman.

For example, if the number of diagnoses is low, but the amount and complexity of data and level of risk are both moderate, your MDM score is moderate. An alternative method to determine the correct level of MDM is to eliminate the highest and lowest scores, and the remaining score is the level for the particular MDM in question.

Bonus: Refer to the sidebar on page 4 for an example of how to use the Marshfield point system with a clinical scenario.