General Surgery Coding Alert

E/M Skills:

Focus Your E/M Code Selection With MDM Shortcuts

Published on Fri Jun 17, 2022

Tip: Undiagnosed conditions should count in your calculations.

If you still have some uncertainty about assessing medical decision making (MDM) when you’re coding office and other outpatient evaluation and management (E/M) services, we have some help for you.

Do this: Study the following Q/As from Rae Jimenez, CPC, CDEO, CIC, CPB, CPMA, CPPM, CCS, senior vice president of products at AAPC, which she answered in “2021 E/M Lessons Learned,” her recent presentation at HealthCon 2022.

Don’t Jump to the Table

Based on the 2021 CPT^® overhaul of codes 99202-99205 (Office or other outpatient visit for the evaluation and management of a new patient …) and 99212-99215 (Office or other outpatient visit for the evaluation and management of an established patient …), you should be basing your outpatient E/M code selection either on time or on MDM instead of all three components of history, examination, and MDM as we used to do. That’s left many coders wondering the following:

Question: Is the MDM table the best place to start when selecting an outpatient E/M code?

Answer: No. When trying to calculate the level of MDM for a particular encounter, don’t make the mistake of simply using the MDM table to assign an office/outpatient E/M code. There are other tools at your disposal to help make this part of your job easier. “Many people go right to the MDM grid and miss all the important information in the guidelines, including the definitions, that precede it,” Jimenez noted.

And remember: Recent additions to ICD-10 have included many new codes that may be used to document Social Determinants of Health (Z55-Z65). As long as the condition is documented in the MDM assessment and plan, “these new codes can be part of documenting circumstances in the patient’s life that support a moderate level of risk when those circumstances significantly limit diagnosis or treatment,” advises Jan Blanchard, CPC, CPEDC, CPMA, pediatric solutions consultant at Vermont-based PCC.

Evaluate Risk and Complexity for MDM Level

Risk and complexity inherent in the patient’s situation impact your MDM level selection. Look at the following three questions to see how these factors come into play.

Question: What level of risk is over-the-counter (OTC) medication?

Answer: Even though OTC medication is not listed as an example in the risk element column, you should not automatically assume that that it cannot be counted into the risk calculation, or that it is only counted at a low level. If the surgeon notes the item as part of the consideration for the assessment and plan, you may consider it.

“You have to look at the complexity of underlying conditions that the patient might have. If the patient has something very acute, like a cold, and an underlying condition, OTC medication is going to be at a more moderate level of risk than low because OTC medication is not always a low level of risk to the patient,” Jimenez pointed out.

Question: What level of risk is COVID testing?

Answer: This depends so much on the complexity and the nuances of the patient’s condition. “A condition does not equal a code. You need to also consider whether the patient has symptoms, whether the patient has respiratory complications, what the provider is recommending, and so on. It goes way past just the condition that they’re being treated for — it’s also about what the data requirements are going to be as well as the risks involved in the MDM,” Jimenez noted.

Question: If multiple providers order multiple lab results or test results, what is the best practice for using those toward MDM?

Answer: “Before I drive myself crazy counting data, I always start with the complexity of the condition, as well as the risks associated with treatment, and see what level I’m coming up to,” Jimenez said. “Ask, ‘do you need that information in order to support a higher level?’”

“Because you can use two out of the three MDM elements, I wouldn’t spend time calculating data unless it was going to mean the difference between one level and another that was medically necessary. I see if the level resonates with the service rendered,” Jimenez advised.

And remember: If you do count tests as part of your MDM calculation, only count results-only tests as data elements per the MDM guidelines. Point-of-care tests, like rapid strep tests that only have a technical component, can be considered toward MDM data on the date of the encounter. But “if you are billing separately for the interpretation, you’re not going to be able to count that. You’re getting paid for that within the interpretation,” according to Jimenez.

Also, even though some have interpreted the separate bullets on the grid for ordering and review of tests as meaning you can get credit for both the ordering and review of the same test, this is not the case. “The expectation is that, if you are ordering the test, you are going to review it, and if you don’t review it, you are not reviewing the data as intended, so the test is not medically necessary,” Jimenez cautioned.

Avoid ‘Acute’ Assumption Trap

When the medical record mentions an “acute” condition, you can’t jump to conclusions about how that impacts MDM. The following questions offer a nuanced view of how acute illness impacts MDM:

Question: Does an acute illness with systemic symptoms automatically mean a moderate level of problem complexity?

Answer: This is one of those MDM elements where you need to turn to the definition provided in the E/M Services Guidelines. Here, the example of fever given in the guidelines helps. “A patient might have a fever with upper respiratory problems, but that patient is not suspected to have a high risk of morbidity without treatment,” Jimenez noted. So, that would not necessarily enable the condition to rise to a moderate level of complexity.

Once again, “differential diagnoses will help us understand the acuity and complexity of that particular service,” Jimenez said.

Question: When added together, do multiple acute uncomplicated illnesses or injuries rise to a moderate level of problem complexity?

Answer: Even though such conditions are more closely aligned with low-level MDM, “they could qualify for moderate,” in Jimenez’s opinion, with one important caveat that remains true in every MDM calculation: “You’ll never pick an E/M based on one element of MDM. We need two out of the three,” Jimenez cautioned.

Grapple with Uncertain Diagnoses

When the patient’s diagnosis isn’t clear, some coders think that automatically indicates a moderately-complex problem.

Question: Does an undiagnosed new problem with uncertain diagnosis automatically mean a moderate level of problem complexity?

Answer: Confusion here revolves around the different ways ICD-10_CM and CPT^®operate regarding uncertain diagnoses. With ICD-10-CM, you are bound by Guideline IV.H, which tells outpatient coders not to code a condition documented “as ‘probable,’ ‘suspected,’ ‘questionable,’ ‘rule out,’ ‘compatible with,’ ‘consistent with,’ or ‘working diagnosis’ or other similar terms indicating uncertainty.”

However, a condition that is undiagnosed as of the date of service (DOS) has to factor into the MDM calculation for the E/M service. For example, a rash could just be a case of contact dermatitis, but if a provider has a suspicion that it could be a more serious health condition, the differential diagnosis needs to be documented. This shows the complexity of the encounter, which will very often rise to the moderate level of MDM for such conditions.

In other words, “We don’t select a probable or rule out ICD-10 code for the diagnosis portion of the encounter, but we never meant for them to be undocumented,” Jimenez noted.