EM Coding Alert

Gain specific insight into the MDM elements.

This time of year, school-aged athletes are gearing up for a new season. For pediatric coders, that means the coming months may see an increase in sports-related injuries.

In his HEALTHCON 2024 presentation, “Clinical Perspective of Sports Medicine Coding From an Athletic Trainer,” Nate Felt, MS, ATC, PTA, CPC, senior consultant for orthopedic, sports medicine, and radiology physicians coding at Intermountain Health in Salt Lake City, Utah, discussed the ins and outs of correctly coding evaluation and management (E/M) encounters. The session offered up some great advice that you can put to good use the next time your pediatrician works with high school athletes diagnosing, treating, and perhaps even preventing, minor muscle and bone injuries.

Understand the MDM Table

In non-surgical sports medicine, E/M services are bread-and-butter. A pediatrician will often be the first healthcare provider to see student athletes with injuries, and at that first appointment, the pediatrician will perform a medically appropriate exam, evaluate the situation, discuss prevention and treatment with the patient, and either manage the condition or refer out to an orthopedic specialist or athletic trainer. This means it’s imperative the pediatrician fully understands the elements of medical decision making (MDM) and document all thought processes. Here are some common circumstances pediatricians may encounter and how to think of them in terms of MDM elements.

“Simple” Sprains: Many professionals and payers consider sprains to be pretty simple and count as an acute, uncomplicated illness or injury. “I struggle with this terminology, and it’s interesting that the AMA put sprains in as an example of this. An ankle sprain is never simple,” said Felt. Pediatricians and athletic trainers alike need to make sure they treat an ankle sprain correctly from the start, or the patient is likely to re-injure if there’s any instability. Documentation is the key, “because if the notes makes it look like a simple ankle sprain, then it’s a simple ankle sprain.” Each person is different. An average athlete who sprains an ankle is more likely than a sedentary person to re-injure that ankle. Documenting the evaluation, management, discussions, risks, and other circumstances in each individual case is going to help you justify the level of service provided.

X-Rays and double-dipping: When you’re trying to level the E/M encounter, be careful when it comes to X-rays. X-rays will rarely count toward your MDM. Let’s say you order the X-rays, take them, then bill for them. Many providers do that and then think they can also count the interpretation as part of MDM. That, however, is double-dipping because you’ve already billed for that.

Independent interpretation: Let’s say your pediatrician sends a patient for an MRI, the radiologist reads the MRI, but the pediatrician doesn’t trust the radiologist. “They pull up the MRI images, and do their own official interpretation,” said Felt. This could potentially apply to X-rays also, but no matter what the circumstances, you need to make sure the documentation is clear and is not simply a carbon copy of what the radiologist reported. Your documentation needs to show additional findings that weren’t in the original report, or the language needs to otherwise show that there was a significantly independent interpretation of the imaging. If valid, “this could be a level 4 in that middle [data] column,” said Felt. If the criteria from that first column also support a level 4, “then this independent interpretation could make a significant difference,” he elaborated.

External physician: Similarly, if a pediatric patient breaks their foot, and the bone displacement is borderline, the pediatrician will refer out the to a sports medicine doctor. The pediatrician might walk across the hall to consult with an orthopedic surgeon who has treated a lot of foot injuries. This discussion with an external physician can count toward your level. “An external physician is not in your same specialty and not in your same group practice,” said Felt. If your consulting physician meets these criteria, “you’ve got to make sure to get these details in the notes,” he continued.

Independent historian: Never underestimate the power of an independent historian. Having a parent or guardian of a young athlete present during the encounter can effectively bump you up to a higher level. If the patient fell, hurt their foot, and is panicking or otherwise unable to communicate and the parent needs to relay what happened and be an active participant in the encounter, that counts as an independent historian. This can significantly contribute to the complexity of data reviewed, which is one of the elements considered when determining the proper level of an encounter.

Be Thorough in Your Documentation

The payer is objectively looking at the claim and at the attached documentation. The payer is also not usually a clinician. If it’s not documented, it might as well have not happened.

Felt concluded by offering up an example of how to make documentation clear and specific and receive credit for the work from the independent interpretation scenario above. In this case, if your pediatrician’s independent interpretation is just about identical to the radiologist’s report, the payer may not count that as justification of independent interpretation. The pediatrician may have done the work, but it doesn’t look like it from the notes.

So, for this scenario, the pediatrician needs to write out something like, “I independently reviewed and interpreted X-rays and MRIs previously done by the radiologist. My findings match the radiologist’s findings, but in addition, I also noticed dysplasia,” instructed Felt.