EM Coding Alert

Question: I am writing for some guidance on Medical Decision Making (MDM) E/M coding for visit where PCP provides preoperative clearance for established patient that is having surgery with a specialist. Where does this fall on the table of risk in MDM? Can you provide some examples of what would constitute a high vs. moderate or low MDM?

Alabama Subscriber

Answer: The table of risk is only one component of medical decision making, but the rule of thumb is that if the patient is having major surgery and there are no risk factors or a minor procedure with risk factors that might make the surgery more dangerous for her, you would assign moderate risk.

But risk alone does not determine medical decision-making complexity. Two other components also must be considered as well, and these are usually the ones that decrease the medical decision-making to a lower level than with risk alone.

First, there is the diagnostic or management options component. A single established problem which is under control puts diagnostic options at the minimal level. If the problem being cleared is more than one condition, you might edge up to a limited level or possibly moderate (for

many additional conditions requiring clearance). If the management option is a particular surgery, the level is still minimal. If the problem is not under control, the chances are that surgery will not be recommended at this time, but this finding would then impact management options to perhaps a limited or moderate level.

Then there is the data reviewed component. If lab and radiological tests are reviewed as part of the clearance, you would be at a limited level for data review. If only lab tests are reviewed, then it would decrease to minimal data.

Now despite moderate risk, you might have only minimal diagnostic/management options and limited complexity of data reviewed. You must meet or exceed two of the three, so the data review being limited would be the determining factor for minimal, limited, or moderate combinations.

You can only get to moderate complexity of medical decision making with a moderate level in either the data reviewed or diagnostic/management options component. So, even if your physician performs a comprehensive examination or history for this established patient, medical decision making will be the final determiner of the level of service — usually a 99213 (Office or other outpatient visit for the evaluation and management of an established patient …), though sometimes a 99214 (Office or other outpatient visit for the evaluation and management of an established patient …) may be documented.