Ophthalmology and Optometry Coding Alert

Although the medical decision making (MDM) table in CPT^® is a handy tool, it has a reputation for being subjective and sometimes confusing, even for experienced evaluation and management (E/M) coders.

Each column comes with its own frequently misinterpreted concepts, and we’re here to clear up some of that confusion. We asked our experts to set the record straight and shed light on some of the grey areas inherent to MDM leveling. Read on for valuable suggestions that can assist you in navigating the nuances of the table elements and correctly identifying the level of MDM each time your clinician performs an E/M service.

Rethink Terms To Better Assess Problem Number, Severity

Because CPT^® rolled out significant changes to the MDM table for outpatient coders in 2021, by the time they published the new table for inpatient coders in 2023, most ophthalmology coders were already up to speed with the new leveling guidelines. However, some new and existing verbiage pertaining to the Number and Complexity element is creating more questions for some coders than answers.

Acute: As of 2023, the Number and Complexity of Problems Addressed column includes “1 stable, acute illness” in the list of examples of low-level MDM.

“I often see coders assuming that ‘acute’ must equate ‘new,’ explains Jacob Swartzwelder, CPC, CRC, CIC, CEMC, AAPC Approved Instructor, managing director at Compliant Approach Partners, LLC in Las Vegas, during his session “E/M Audits for Primary Care” at HEALTHCON Regional 2023 in Washington, DC.

The condition does not have to be new. In fact, CPT^® E/M guidelines define an acute, uncomplicated illness or injury as a “recent or new short-term problem with low risk of morbidity for which treatment is considered.” Thus, you can safely interpret “acute” to include follow-up to an acute, uncomplicated injury or illness.

“Just ensure treatment has previously been initiated and the condition is not fully resolved,” says Swartzwelder. Remember, you’re aligning with low overall MDM. “Generally, medically necessary follow-up for a resolved condition will align with straightforward overall MDM,” he continues.

Self-limited or minor: Coders are often confused by classifying patient conditions as “self-limited” or “minor.” Providers don’t use these words exclusively to describe patient problems, so when you’re considering the patient’s condition, think about whether it could have resolved on its own or could have been effectively treated at home without the physician. “Ophthalmic examples include subconjunctival hemorrhage, mild dry eye, or other non-vision-threatening conditions that are likely to resolve on their own; patients are often given something for comfort only,” notes Mary Pat Johnson, CPC, CPMA, COMT, COE, senior consultant with Corcoran Consulting Group.

From a CPT^® perspective, a self-limited or minor problem is one “that runs a definite and prescribed course, is transient in nature, and is not likely to permanently alter health status.”

Exacerbation: This term refers to a significant worsening, poor control, and/or escalation of a patient’s symptoms or conditions.

The higher the MDM level consideration, the more payers will be looking at your documentation to show exacerbation.

“You can have a chronic illness with exacerbation, but if you don’t tell me the severity of the exacerbation in the documentation, I have to assume moderate. The treatment plan should correspond with the notes about severity of exacerbation,” says Swartzwelder. In other words, if your provider’s notes are not clear in this regard, use this as an opportunity for education, at best, and a query, at least.

Don’t Stumble Over ‘Amount and/or Complexity of Data’

The Amount and/or Complexity of Data to Be Reviewed and Analyzed column is notorious for giving coders pause. Understanding the complexity of data often requires medical knowledge, which is why the provider’s documentation is so important. If the notes aren’t clear enough for you to accurately use this column to assign a level to the encounter, you should query the provider. However, if the information doesn’t affect the level, don’t let it derail you. Remember, you only need two out of the three elements.

“In ophthalmic encounters, the data component is usually your weakest component, which means you can oftentimes level the encounter without the data element,” Johnson adds.

“I wouldn’t spend time calculating data unless it was going to mean the difference between one level and another that was medically necessary,” advised Rae Jimenez, CPC, CDEO, CIC, CPB, CPMA, CPPM, CCS, senior vice president of products at AAPC, in her presentation “2021 E/M Lessons Learned,” at HEALTHCON 2022.

That’s not to say you should overlook opportunities for provider education when it comes to the data element. However, try to separate that from the information that’s truly needed to level an encounter accurately.

Expert tip: “Zoom out to see the larger picture. The entire encounter should flow and be consistent with the level of service selected. No element of MDM should drastically alter the overall level of service,” explains Swartzwelder.

Remember That Risk of Complications Refers to the Plan

Like the Data element, the Risk of Complications and/or Morbidity or Mortality element is multifaceted. The important thing to remember is that the word “risk” refers to the management plan (diagnostic procedures, treatments, etc.), not the patient’s symptoms and general condition.

Consider what the CPT^® E/M guidelines state:

“The assessment of the level of risk is affected by the nature of the event under consideration. For example, a low probability of death may be high risk, whereas a high chance of a minor, self-limited adverse effect of treatment may be low risk. Definitions of risk are based upon the usual behavior and thought processes of a physician or other qualified health care professional in the same specialty.”

“Think of this as what risk, if any, is being added by the management options considered — monitoring a condition adds minimal, if any, risk. Minor surgery or [over-the-counter] OTC medications may add risk. Major surgery or prescription medications may add different risks,” says Johnson. “The AMA’s E/M guidelines even address patients with identified risk factors that may elevate your scoring of the management level in E/M coding,” she notes.

In other words, the clinician defines the risk of complication or morbidity based on the circumstances, and while quantification is not necessarily required, you may want to establish an ongoing dialogue with the provider so you can better understand their thought process. If the provider doesn’t clearly indicate the level of risk, without clarification you should default to the lowest level to avoid compliance risk.