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 of the overall level of MDM.

/B>Points for Review of Tests and Patient History

The categories and point values for the amount and/or complexity of data to be reviewed are as follows:

The review and/or ordering of clinical lab tests are assigned one point. Examples of clinical tests frequently ordered by gastroenterologists include a complete blood count (CBC), CLO (campylobacter- like organism) test, or a liver profile. Only one point is given in this category regardless of the number of clinical tests ordered, says Stout, who adds that credit is given for either the ordering or review of a test, but not both.

The review and/or ordering of tests in the radiology section of CPT, including all nuclear medicine and imaging, except echocardiography and cardiac catheterization, are assigned one point. Examples of radiological tests frequently ordered by gastroen- terologists include a barium enema, a liver scan and a CT (computerized tomography) scan of the abdomen. Again, only one point is given in this category regardless of the number of radiological tests ordered, and credit is given for either the ordering or review of test.

The review and/or ordering of tests in the medicine section of CPT are assigned one point. Examples
of medical tests frequently ordered by gastroenterol- ogists include EKGs and gastrointestinal motility studies. As with the other categories, only one point is assigned for all medical tests ordered, and credit is given for either the ordering or review of the test. Stout adds that only reports of endoscopy procedures that are listed in the medicine section of CPT (90281-99199) qualify for credit in this category.

The discussion of test results with the performing physician is assigned one point. After the gastroen- terologist orders a test, he or she may find it necessary to talk with the physician who performed the test to receive an immediate assessment of
the patient.

In a situation where the gastroenterologist feels a large mass in the patients abdomen and sends him or her to the radiologist for a CT scan, the radiologist may call the gastroenterologist with the results so that the patient can be admitted immediately to the hospital if necessary, explains Stout. If that phone call occurs on the same day as the E/M service, the gastroenterologist should receive credit in this category.

The decision to obtain old records and/or a history from someone other than the patient and/or discussion of the case with another healthcare provider is assigned one point. This occurs when a patient gives the gastroenterologist authorization to obtain old medical records which, according to Leineke, happens all the time.

Credit also is given when the patient is uncommu- nicative, and the gastroenterologist has to get a history from a member of the family or caretaker, Leineke adds.

The review and summarization of old records and/or obtaining a history from someone other than patient and/or discussion of the case with another healthcare provider is assigned two points. To receive credit in this category, the findings have to be relevant to the patients current complaint, says Leineke. The gastroenterologist needs to elaborate on the findings in the documentation of the medical record. A notation of old records reviewed or additional history obtained from family without elaboration is not sufficient.

The Health Care Financing Administration (HCFA) gives you a break here, says Stout. The gastroenterologist can get credit in one E/M encounter for deciding to obtain a patients old medical records and get credit in the next E/M encounter with that patient for the review and summarization of those old records.

The independent visualization of an image, tracing or specimen itself, not simply a review of the report, is assigned two points. To receive credit in this category, the gastroenterologist must be looking at the original test or study and coming up with his or her own interpretation. A patient may bring in a set of x-rays for the gastroenterologist to review, notes Stout. Or the gastroenterologist could do the analysis of a CLO test.

Proper Documentation Required

Proper documentation of the data reviewed will include three elements, according to Stephanie Jones, CPC, a multispecialty coding consultant in Boca Raton, Fla. There should be a notation of the review in the patients medical record that the gastroenterologist signs or initials and dates, she says. In addition, the date of the review or date when the test was ordered should match the date when the E/M service was reported.

If the test is either not ordered or reviewed on the day of the E/M encounter, there could be problems getting credit for the review. The gastroenterologist may want to wait two weeks after the E/M encounter occurs to order a test so that the patient can start a new drug treatment, Stout explains. Because the test was not ordered on the same day as the E/M service, then it may not count as part of the amount and complexity of data reviewed.

The notation of the review in the patients medical record can be very simple. If the gastroenterologist is using a cheat sheet, the phrase Lab work of (fill in the date) reviewed and noted will be printed on a form, Stout says. Then the gastroenterologist will either write no change or jot down a comparison of this result to previous test results.

Number of Points Related to Level of MDM

The number of points for each category is added to arrive at a total for the amount and/or complexity of data to be reviewed.

One point or fewer is considered a minimal or low amount and/or complexity of data to be reviewed, which is one of the components of straightforward MDM.

Two points are considered a limited amount and/or complexity of data to be reviewed, which is one of the components of low complexity MDM.

Three points are considered a moderate amount
and/or complexity of data to be reviewed, which
is one of the components of moderate complexity MDM.

Four points are considered an extensive amount and/or complexity of data to be reviewed, which is one of the components of high-complexity MDM.

Although this system is widely accepted, not all Medicare carriers assign the same point values to each category. Auditors in Florida, for example, only assign one point to each category of data reviewed, Jones reports. This means that gastroenterologists in Florida only receive one point instead of two for reviewing and summarizing old records or for interpreting tests.

Note: Copies of the E/M Documentation Auditors Worksheet can be ordered from the Medical Group Management Association by calling (303) 397-7888.