Gastroenterology Coding Alert

Gastroenterologists often overlook the amount and complexity of data reviewed during a patient encounter when documenting the medical decision-making (MDM) component of an evaluation and management (E/M) service. The use of a widely accepted auditors worksheet can simplify the process of calculating the amount of data that was reviewed during the E/M service.

MDM, according to the CPT, refers to the complexity of establishing a diagnosis and/or selecting a management option. It should be the driving force behind the E/M encounter, says Janet Leineke, CCS, CPC-H, senior outpatient consultant for Laguna Medical Systems, a health information management consulting, outsourcing and education services company headquartered in San Clemente, Calif. If the patient has a minor problem and the medical decision-making is straightforward or low complexity, the history and examination will be simple and noninvasive. If the problem is more significant or life-threatening, the medical decision-making will be of moderate to high complexity.

Elements to Consider for MDM

There are four overall levels of MDM:

1. straightforward (a component of a Level I or II E/M service);
2. low complexity (a component of a Level III
E/M service);
3. moderate complexity (a component of a Level IV E/M service); and
4. high complexity (a component of a Level V
E/M service).

To determine the overall level of MDM, the highest two levels of the following three elements are considered:

The number of possible diagnoses and/or the number of management options that must be considered;
The risk of significant complications, morbidity and/or mortality, as well as comorbidities, associated with the patients presenting problem(s), the diagnostic procedure(s) and/or the possible management options; and
The amount and/or complexity of medical records, diagnostic tests, and/or other information that must be obtained, reviewed and analyzed.

Use of Worksheet Aids Documentation

Gastroenterologists often overlook this last element the amount and/or complexity of medical records, diagnostic tests and/or information that must be obtained, reviewed and analyzed when documenting the medical record. Gastroenterologists usually dont score well in this area during an audit, says Pat Stout, CMT, CPC, an independent gastroenterology coding consultant in Knoxville, Tenn. They do things like review lab work,
x-rays and electrocardiograms (EKGs), but those items arent always documented in the patients medical record.

To ensure that those items get documented and the gastroenterologist receives credit for the medical data that was reviewed during the E/M service, many practices will use the method employed by Medicare auditors to quantify the amount and/or complexity of data reviewed. The system, which also can be used for other components of the E/M service, assigns points according to the type of medical data reviewed and then arrives at a total score that can be included in the determination [...]