EM Coding Alert

Evaluate all available information when determining risk.

Assessing murky situations to define medical decision making (MDM) levels can seem daunting for rookie coders and even seasoned veterans. But this step in finding the correct evaluation and management (E/M) doesn’t have to be a headache.

Know That a Patient May Refuse a Test

Scenario 1: The physician orders a spirometry, but the patient refuses to undergo the test. You’re trying to determine the encounter’s complexity level, which leads you to wondering whether the physician should still get credit for the order.

What you should know: Physicians frequently recommend a test that the patient ends up declining for one reason or another (for example, financial concerns or reservations about risks). The recommendation itself reflects the provider’s clinical judgment and expertise. However, if they determine the test is necessary, either to diagnose or otherwise manage the patient’s condition, that determination can impact each of the amount and/or complexity of data to be reviewed and analyzed section of MDM. As the CPT^® MDM guidelines for this section state, “Ordering a test may include those considered but not selected after shared decision making.”

Factoring in the physician’s order makes sense, because if the physician went through the process to determine the patient needed a particular test, even though the patient didn’t follow through, that still constitutes MDM on the physician’s part.

What to do: You should factor the physician’s order into the MDM or care/treatment plan. Be sure that the doctor documents the fact that they ordered the test, but the patient refused it. If possible, the provider should also record why the patient refused the test. Remember, the more the record expounds on the thought-process behind ordering the test, the easier it will be to prove that the physician should receive credit for it.

Also: The patient’s refusal might even increase the complexity of the MDM, as the physician must now consider alternative methods for diagnosis or treatment, or the potential risks of not performing the test.

Understand Elements of Drug Management

Scenario 2: A patient continues their prescription drug treatment with no changes of medication or dosage. You’re wondering what qualifies as prescription drug management, in terms of the moderate-risk level in the complications and/ or morbidity or mortality of patient management element of MDM.

What you should know: CPT^® currently has no explicit guidelines for this. However, you can get a sense of how MDM for this element plays out by looking to Medicare’s directions for prescription drug management.

According to Novitas Solutions, a Part A/B Medicare Administrative Contractor (MAC), you can get MDM credit for prescription drug management “when documentation indicates medical management of the prescription drug by the physician who is rendering the service. Medical management includes a new drug being prescribed, a change to an existing prescription or simply refilling a current medication. The drug and dosage should be documented as well as the drug management” (www.novitas-solutions.com/webcenter/portal/MedicareJL/ pagebyid?contentId=00005056).

This indicates you should note the drug and the amount prescribed along with a note showing your provider has decided to either change — or not change — the prescription drug during the encounter. Simply put, without documenting these three things, you will not be able to justify a moderate level of MDM based on prescription drug management.

This Medicare guidance is similar to guidance included in CPT^® Assistant (Volume 33, Issue 9, 2023), which states, “Similar to MDM regarding a medication (over the counter or prescription), just noting the drug is not management. Deciding to continue or change therapy is management, but the risk is specific to the patient.” Likewise, “Renewing or changing medication in the medication list through an extension or new prescription would represent medication management of the prescribed and OTC medications for that patient…. Therefore, simply reviewing a medication list does not constitute prescription drug management,” according to CPT^® Assistant (Volume 32, issue 11, 2022).

Expert tip: “Sometimes I think we forget to zoom out and see the larger picture. The entire encounter should flow and be consistent with the level of service selected,” explains Jacob Swartzwelder, CPC, CRC, CIC, CEMC, AAPC Approved Instructor, managing director at Compliant Approach Partners LLC in Las Vegas. In other words, no one element should drastically alter the overall level of service. Keep this in mind when questions such as this one come up.

Define Risk Carefully

Scenario 3: A patient presents for an evaluation to determine if they’re a candidate for laparoscopic surgery. You’re wondering where this encounter fits into the risk column of the MDM table.

What you should know: The important thing to remember is that the word “risk” refers to the probability and/or consequences of an event related to the treatment plan.” Consider what the CPT^® E/M guidelines state:

“The assessment of the level of risk is affected by the nature of the event under consideration. For example, a low probability of death may be high risk, whereas a high chance of a minor, self-limited adverse effect of treatment may be low risk. Definitions of risk are based upon the usual behavior and thought processes of a physician or other qualified health care professional in the same specialty.”

What you should do: Pay close attention to the documentation from the encounter, the details surrounding the order, and any comorbid conditions. For example, a patient may have a chronic condition, such as chronic obstructive pulmonary disease (COPD), that should be considered before clearing the patient for laparoscopic surgery. The procedure itself carries risks of complications, but the probability and/or consequences of those complications may depend on various factors, including the patient’s current health status, the potential for complications from the surgery, and the urgency of the treatment. In the case of a laparoscopic surgery, the risk of not treating is also a factor and may very well be considered high, given the serious complications that can arise following the procedure. In the case of a laparoscopic surgery, a pulmonologist assessing a COPD patient for the surgical procedure without additional prescription management wouldn’t achieve a moderate risk for just clearing the patient. But the pulmonologist ordering a bronchoscopy uses the procedure to judge the patient’s eligibility for surgery, which meets a moderate risk.

Remember: Try to not get hung up on one detail. If you’re stuck on one element, look at the other elements to see if the encounter already meets or exceeds that level. “Making a decision for surgery is not the sole determining factor when assigning the MDM or an E/M code. Specifically, ordering a test to determine the patient’s surgery eligibility would contribute to the Risk of Complications/Morbidity column in the 2023 Documentation Guidelines and be combined with the other MDM components to determine the appropriate level of MDM,” says Todd Thomas, CPC, CCS-P, president of ERcoder Inc., in Edmond, Oklahoma.