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Gastroenterology Coding Alert

Reader Question:

Consider 3 Factors When Determining MDM

Published on Tue Jun 08, 2004

Question: One of our newer coders filed an erroneous claim recently in which she assigned a level 3 E/M service when our nurse instructed a patient with hepatitis how to self-inject Interferon. The coder said she didn't understand how to assign the level of medical decision making (MDM). What are some things we can tell her to remember when determining MDM?

Missouri Subscriber

Answer: On the rejected claim, the coder should have reported 99211 (Office or other outpatient visit for the evaluation and management of an established patient, that may not require the presence of the physician. Usually, the presenting problem[s] are minimal. Typically, 5 minutes are spent performing or supervising these services).

When reporting E/M services, you must consider the level of MDM whether you are using the new patient code set (99201-99205; Office or other outpatient visit for the evaluation and management of a new patient, which requires these three key components; ...) or the established patient set (99211-99215; Office or other outpatient visit for the evaluation and management of an established patient ...). (Or any E/M service for that matter -- consults, hospital visit, etc.)

The MDM maze can be hard to navigate when figuring out E/M level. When deciding the difference between straightforward (S), low (L), moderate (M), and high (H) MDM, look at these aspects of the visit:

1. Number of possible diagnoses and/or management options
2. Amount and/or complexity of medical records, diagnostic tests and/or other information that is obtained, reviewed and analyzed
3. Risk of significant complications, morbidity and/or mortality including comorbidities associated with the patient's presenting problem(s), diagnostic procedure(s) and/or the possible management options

Hot tip: When determining level of risk, keep these guidelines in mind:

  • Minimal risk is usually a minor problem -- such as the above example of the patient needing nurse instruction on Interferon injection.
  • Low risk may be more than one minor problem, a chronic illness or an uncomplicated acute illness.
  • Moderate risk can be one or more chronic illness[es] with mild exacerbation, two or more stable chronic illnesses, an undiagnosed problem, acute illness with systemic symptoms, or an acute complicated injury.
  • High risk typically means one or more chronic illness[es] with severe exacerbation or progression, acute or chronic illnesses or injuries that may pose a threat to life or bodily function, or an abrupt change in neurological status.

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