New E/M Guidelines:
Making Sense of Ob-Gyn Medical Decision Making
Published on Wed Apr 01, 1998
One of the most important ingredients for success in todays medical market is the ability to accurately and legally code for the level of services you are providing your patient. Much of coding is fairly straightforward, and simply requires finding the right code to match the procedure or service performed. What is not that simple is coding for Evaluation and Management (E/M) Services, and in particular, the key area of medical decision-making.
According to senior consultant and coding expert Cynthia Thompson, CPC, of Gates, Moore & Company, a medical practice management consulting firm, Medical decision-making is one of the hardest areas of E/M services to grasp and do well. Even with the enforcement of the new E/M guidelines delayed until July 1998, and significant pressure being brought by the specialty societies to change them, Thompson believes coders in ob/gyn practices would do well to strengthen their understanding of medical decision-making in the current guidelines. Its not going to go away, she states. Increasingly, you will need a grasp of the required documentation to code for higher levels.
The Role of Medical Decision-Making
What propels an E/M exam to a higher level of service is how much work, time, thinking, evaluation and risk are involved in the delivery of the service. This investment of effort and energy in providing a specific service is broken down into three key areas: 1) the examination, 2) history, and 3) medical decision-making. The more documented effort and energy invested in each of these areas, the better you can make the argument for coding to a higher level of service and being reimbursed at a higher rate.
Medical decision-making is really the pivot point of the whole process of evaluating and managing a patient. In this key step, the provider carefully looks at all the facts concerning the patient and makes decisions regarding diagnosis and selecting a course of management. The CPT ranks this process of establishing a diagnosis and deciding on a management strategy into four categories based on how complex the medical decision-making process is. These categories are:
1. Straightforward
2. Low Complexity
3. Moderate Complexity
4. High Complexity
To qualify for one of these four levels, the service provided must meet certain requirements in the following three areas:
1. the number of possible diagnoses and/or the number of management options that must be considered.
2. the amount and/or complexity of medical records, diagnostic tests, and/or other information that must be obtained, reviewed and analyzed.
3. the risk of significant complications, morbidity and/or mortality, as well as comorbidities associated with the:
a. patients presenting problem(s),
b. diagnostic procedures, and/or
c. possible management options.
The difficulty of medical decision-making, Thompson explains, is that these measurements are subjective and up [...]
