Ob-Gyn Coding Alert

Question: Our providers say that referrals are always considered low risk under the Risk of Complications and/or Morbidity or Mortality of Patient Management column of the levels of medical decision making (MDM) table. If the provider documents the conditions as worsening or new and requiring additional workup outside the scope of the practice, and therefore documents a referral to a specialist, is this a low level of MDM based on columns 1 and 3?

AAPC Forum Participant

Answer: A referral can count toward MDM, but a referral itself doesn’t translate into a specific risk level on its own. Determining the level of MDM depends on the patient’s circumstances and the work put in by the provider, even if that provider ultimately decides to refer the patient to a specialist.

Consider the following:

If a patient sees their ob-gyn for a complaint of urinary incontinence and during the exam a potential prolapse issue is found and the patient is referred to a gyn/urologist for further evaluation, it’s reasonable to regard that scenario

as low risk for MDM. However, suppose a patient presents with symptoms of low back pain, pelvic pain, and recent vaginal bleeding following menopause. The patient has a family history of ovarian cancer, and the provider counsels the patient during the visit about possible testing, reviews current medications, activity level, drug and alcohol use, as well as surgery and other treatment options. In this situation, a lot went into the encounter, and referring that patient to a gyn-oncologist may be in order. Even with a referral, the “risk” in terms of MDM (that is, the risk of complications and/or morbidity or mortality of patient management) is great and may contribute to bumping the visit up to a moderate level.

The CPT^® Evaluation and Management (E/M) Services guidelines outline the criteria like this: “The risk of patient management criteria applies to the patient management decisions made by the reporting physician or other qualified health care professional as part of the reported encounter.” The decision to refer the patient may involve more than a low level of risk.

Additionally, the level of MDM does not depend solely on the level of risk. The other two columns in the MDM table (Number and Complexity of Problems Addressed at the Encounter and Amount and/or Complexity of Data to be Reviewed and Analyzed) also play a role. The level reached in all three columns should be considered when determining the level of MDM, since the level of MDM requires meeting the requirements of two of the three columns.

In the end, the ob-gyn provided the E/M service, and you would base the level of MDM on the work and expertise of that provider at the time of the encounter, regardless of whether the patient follows the advice or is ultimately referred to another provider. The credit is given to the provider because of the use of their training, education, research, and time spent coming to a particular decision.