General Surgery Coding Alert

See how to tally number and complexity of problems.

With nearly a year of reporting E/M services based on revisions to 99202-99215 (Office or other outpatient visit …), several questions persist among surgery coders regarding how to code based on medical decision making (MDM).

Let our experts help you put these questions to bed with the following Q&A.

Pinpoint Necessary MDM Elements

Question 1: Must we document all three MDM elements when choosing an office E/M code not based on time?

Answer 1: No, you don’t have to document all three MDM elements. Two out of three elements can dictate MDM level, according to Terri Brame Joy, MBA, CPC, COC, CGSC, CPC-I, billing specialty subject matter expert at Kareo in Irvine, Calif.

The confusion on this point may stem from the fact that the MDM table includes the following three elements that can help you select the MDM level:

• Number and complexity of problems addressed
• Amount and/or complexity of data to be reviewed and analyzed
• Risk of complications and/or morbidity or mortality of patient management

If you’re poring over charts and reports trying to pinpoint an MDM level because you want to meet all three criteria, keep in mind that you must only meet two of the three to justify a particular MDM level, according to CPT^® guidelines.

“This means that if one area is weak, we are able to drop it,” says Barbara J. Cobuzzi, MBA, CPC, COC, CPC-P, CPC-I, CENTC, CPCO, CMCS, of CRN Healthcare in Tinton Falls, New Jersey.

Tip: You might want to avoid using amount and/or complexity of data as one of the two MDM elements, in many cases. “Counting the data elements can be a challenge. There are a lot of variables that you can have arguments with payers about in terms of collection of data,” Cobuzzi says.

Instead: “It’s my recommendation that, when possible, you concentrate on the number and complexity of problems being addressed during your encounter … and then also focus on the risk of complications and morbidity or mortality of patient management,” Cobuzzi says.

Focus on “Problem”

Question 2: What exactly counts as a “problem,” and should I count all problems, or just the specific problem the surgeon is addressing at the encounter?

Answer 2: “A problem is a disease, condition, illness, injury, symptom, sign, finding, complaint, or other matter addressed at the encounter, with or without a diagnosis being established at the time of the encounter,” according to CPT^® guidelines.

Count them all: Even though you’re ultimately going to assign just one diagnosis to the patient’s claim for the visit, you should count each problem addressed. If your surgeon sees a patient with a high number of differential diagnoses, you should list them all to justify MDM, according to Brame Joy.

Symptoms, too: A patient may present with a sign or symptom for which the clinician doesn’t establish a diagnosis during that visit. “However, evaluating it still adds complexity to that visit,” Cobuzzi says, so you should still count it as a problem in the MDM.

For example: A patient may come to the office for a wound that isn’t healing. If the surgeon documents swelling at the wound site and a fever, plus that the patient has diabetes, each of those findings contributes to the number and complexity of problems addressed during the encounter.

Question 3: Is counting the problems enough, or must the documentation show how the physician addresses the problem(s)?

Answer 3: The point of documenting all the problems addressed by the physician during a visit is to make sure a payer would be able to visualize the thought process they used while analyzing a patient’s problems and managing them, according to Cobuzzi.

Advice to physicians: “You want to think and ink,” Cobuzzi says. “Take everything you’re thinking and record it as part of the medical decision making.”

Record Treatment Goals

Question 4: How do we establish if a patient’s condition is “unstable,” which qualifies it as moderate rather than low complexity?

Answer 4: This is an important concept, because an unstable condition qualifies as moderate rather than low complexity, which might qualify the encounter for level 4 rather than level 3.