Internal Medicine Coding Alert

Teach your physicians to write iron-clad MDM notes.

You can't get inside your internist's head to know whether his MDM (medical decision-making) warrants the E/M service code that he reported -- but beware that Medicare auditors are zooming in on this area when examining E/M claims.

Auditors aren't scrutinizing the exam or history as much as they weigh the factors related to medical decision-making. But you can be your physician's front line of defense and make sure his notes withstand scrutiny if you follow these tips.

Tip 1: Identify a Mismatch With This Strategy

In your next staff education meeting, remind your internists that medical necessity should be the overarching factor they use to select the E/M service level (such as 99201-99215, Office or other outpatient visit for the evaluation and management of a new or established patient ...). Just because a physician completes a comprehensive history and examination doesn't mean he always should report 99215. Medical necessity should drive the components that he performs.

This mindset is particularly important with the implementation of EHR systems, which automatically code encounters without regard to medical necessity. It is very easy to document high levels of history and exams, particularly for established patients, which will result in level four and five services when the medical necessity may dictate only level two or three services.

"This is a major concern of mine," says Kathleen Goodwin, CPC, CPMA, coding coordinator for La Porte Regional Physician Network in La Porte, In. "These programs should be used as tools to help the doctors, but they shouldn't be relying on the program to determine the level of service."

You can help ensure your physicians are selecting appropriate codes by occasionally pulling a sample of their charts. Look at the patient's chief complaint (meaning the nature of the patient's presenting problem) and the encounter's outcome or final diagnosis. If the primary ICD-9 code and any relevant secondary diagnoses (those representing comorbid conditions) do not support a billed level of service, you should really read the chart notes, says Kent J. Moore, manager of healthcare delivery and financing systems for the American Academy of Family Physicians (AAFP) in Leawood, Kan.

Example: A patient presents with a chief complaint (CC) of sinusitis, which is also the only ICD-9 code that the internist reported: 461.1 (Acute sinusitis; frontal). Although the physician could have performed and documented the elements necessary for a detailed history and detailed examination, the CC of sinusitis probably wouldn't warrant 99214, without any additional comorbidities or complicating factors.

Tip 2: Look for Potential MDM-Boosting Factors

But complicating factors could make 99214 and 461.x a match. The patient might have comorbidities or other chronic conditions that could affect treatment and coding. For example, the patient with sinusitis might have asthma (493.1x, Intrinsic asthma) or emphysema (492.x) that could complicate treatment and warrant the MDM and medical necessity associated with a Level 4 E/M visit. Medications the patient takes or adverse reactions the patient had to previous medications also could increase the level of MDM.

Comorbidities, the need for diagnostic testing, the plan of care, and so on, may complicate the medical decision making as well.

In addition, evaluation of symptoms possibly related to sinusitis (such as fatigue, headache, fever, and cough) can increase the MDM if they lead to additional diagnoses. When you work up a sinusitis, if a patient also has these other symptoms, then you have to make sure he doesn't have any other problems that could be more serious.

The more involved workup usually makes the service a 99214.

Good idea: Ask your physician to list the patient's complicating factors. Unless the chart spells these out, you have no way of knowing that a comorbidity, chronic condition, or medication played a role in raising an office visit's MDM from low (99213) to moderate (99214) complexity.

Tip 3: Give Credit for Clear Management Options

Tell your physicians to clearly indicate when they're taking an intermediate step that they don't believe will solve the patient's problem. For example, they may try antibiotics before a more aggressive treatment.

Explaining that they're trying the more conservative treatment, but that the patient may require a more aggressive approach, can boost the level of MDM, says Marcella Bucknam, CPC, CCS-P, CPC-H, CCS, CPC-P, COBGC, CCC, manager of compliance education for the University of Washington Physicians Compliance Program in Seattle. Documenting the extra step shows that the physician considered more management options (one element of MDM).

Tip 4: Look at Patient's Complexity

Sometimes a low level of MDM (in conjunction with a detailed/comprehensive history and examination) can be associated with a 99214. Remember, established patient office visits require only two of three key components (history, exam, and MDM) for a given level of service. That's why experts say you can't just look at the MDM; you should also look at the complexity of the patient and the associate history and exam.

In the above sinusitis scenarios, a highly complex patient with a sinusitis diagnosis could justify a level-four established patient office visit.

Example: A diabetic patient with methicillin resistant Staphylococcus aureus (MRSA) has suffered for a long time from chronic fungal sinusitis. The sinusitis is finally stable. Because of the patient's complexity, as represented by the comorbid diabetes and MRSA, medical necessity probably justifies the physician performing a comprehensive history and detailed examination. Therefore, you can report 99214. However, the MDM will likely be at a low or straightforward level because you get only one point for the stable, previously established diagnosis when using a typical MDM audit tool. The conditions present moderate risk, and the physician won't be ordering a lot of tests.