Medicare Compliance & Reimbursement

Assign points to each of the three MDM components that your doctor performs to determine the level of MDM.

You know that inappropriate reporting of E/M levels has been inviting significant scrutiny recently. To make matters worse, this is one area that confounds even seasoned coders. Such is the case when addressing a new problem, which can snag you more points than an established one. But many practices struggle to define what makes a new problem “new.”

Good news: Part B MAC Palmetto GBA has given pointers on how to decide the overall level of service for an evaluation and management (E/M) encounter, such as an office visit. It has posted guidance on how to choose medical decision making (MDM) level for you to stay compliant when coding.

Background: To determine the level of MDM, you should assign points to each of the three MDM components that your doctor performs. The number of points in each category determines the final MDM level. There are three elements that contribute to the complexity of the medical decision making: diagnoses/management options, complexity of data reviewed/ordered, and the table of risk. You must have two out of the three MDM components score at a particular level in order to assign that level of MDM.

Understand Each Level of Diagnosis

Start your MDM level assessment by tackling the first category: number of diagnoses. For this category, ask yourself what’s wrong with the patient, and are the diagnoses new? For each diagnosis, you will assign a point and score the diagnosis level as follows:

• Self-limited/minor problem —1 point each, with a max of 2 points
• Established problem, improving/stable — 1 point each
• Established, worsening — 2 points each
• New problem, no planned additional workup — 3 points each, max of 3 points
• New problem, additional workup — 4 points each

So what exactly constitutes a “new” problem? “In most instances, a new problem is one that is new to the provider and being addressed at that visit,” Palmetto said on its website in a June 10 E/M Tip.

“There are two exceptions to this general rule:

• The initial visit of an established beneficiary in a single specialty group practice setting with a new provider
• A visit by an ‘on call’ or covering provider. In these instances, the established problems are treated as if the beneficiary was seen by the unavailable provider.”

Example: An established diabetic patient with hypertension comes in complaining of flank pain. The physician evaluates the patient’s pain and orders bloodwork and a CT scan. The results indicate that the patient has a kidney stone. The doctor also renews prescriptions for the patient’s diabetes and hypertension. The physician has treated one new problem (the kidney stone) and two established (but stable) problems — the hypertension and diabetes.