Neurology & Pain Management Coding Alert

Reader Question:

Don't Risk Undercoding E/Ms

Published on Thu Oct 02, 2003

Question: I am trying to figure out an easy way to determine risk levels for the MDM component of E/M services. Are there guidelines I can use?

South Carolina Subscriber

Answer: As they say on Wall Street, a little risk can have a big payoff, which can also apply to E/M coding -you just have to know risk when you see it.

The medical decision-making component of an E/M service - straightforward, low, moderate or high - is based on three aspects of the visit:

the number of possible diagnoses and/or management options present

the amount and/or complexity of medical records, diagnostic tests and/or other information that is obtained, reviewed and analyzed

the level of risk of significant complications, morbidity and/or mortality including co-morbidities associated with the patient's presenting problem(s), diagnostic procedure(s) and/or the possible management options.

Determining the level of risk is often the hardest of the three medical decision-making components because it requires more than just counting diagnosis options or the number of lab tests ordered.

The risk component includes those risks associated with presenting problems, diagnostic procedures and management options, and the highest level of risk in any of these areas determines the overall level of risk.

Use these descriptions of the four levels of risk to guide your determinations of levels of risk:

Minimal - This level of risk is typically assigned for a patient who presents with one minor problem. Diagnostic procedures at this level usually include laboratory tests requiring venipuncture, x-rays, urinalysis or ultrasounds; management options include rest and simple bandages.

Low - A "low"-risk patient usually presents with two or more minor problems, one stable chronic illness, or an acute uncomplicated illness. The diagnostic procedure required for the patient may include superficial needle biopsies, laboratory tests requiring arterial puncture, non-cardiovascular imaging studies (for example, barium enema) and physiologic tests not under stress. Management options include over-the-counter drugs, minor surgery with no risk factors, therapy, and IV fluids without additives.

Moderate - A patient of "moderate" risk will present with one or more chronic illnesses with mild exacerbation, two or more stable chronic illnesses, an undiagnosed problem, acute illness with systematic symptoms, or an acute complicated injury. The required diagnostic procedures may include physiologic tests under stress, cardiovascular imaging studies with contrast and no risk factors, and obtaining fluid from the body. Management options include minor surgery with identified risk factors, elective major surgery with no risk factors, prescription-drug management, therapeutic nuclear medicine, and IV fluid with additives.

High - A "high" level of risk typically involves a patient with one or more chronic illnesses with severe exacerbation or progression, acute or high chronic illnesses or injuries that may pose a threat to life or bodily function or an abrupt change in neurologic status. "High"-risk diagnostic procedures include imaging studies with contrast and identified risk factors, cardiac electrophysiological tests, and diagnostic endoscopies with risk factors. Management options include elective major surgery with risk factors, emergency major surgery, parenteral-controlled substances, drug therapy requiring intensive monitoring for toxicity, and the decision not to resuscitate or to de-escalate care because of poor prognosis.

A reminder from the Medicare Carriers Manual: Medical necessity of a service is the overarching criterion for payment in addition to the individual requirements of a CPT code, so it is not appropriate or medically necessary to bill a higher-level E/M service when a lower level is warranted. The volume of documentation should not be the primary influence on which a specific level of service is billed, but should support the level of service reported.