Ophthalmology and Optometry Coding Alert

Question: We used to report only ophthalmological services codes, but now our doctors want us to report more E/M codes because in some cases they pay more. Can you explain the basics of coding medical decision-making as part of an E/M service?

Codify Subscriber

Answer: Whenever your eye care physician performs an E/M service, you will have to scour patient documentation to ensure that your clinician has documented all the pertinent components of history, examination, and medical decision-making. For new patients, you’ll need to meet the criteria of all three of these elements, and for established patients you’ll have to meet two of the three.

Medical decision-making reflects the intensity of the cognitive labor performed by the physician. When checking on MDM, you will have to check for these three elements, and you can assign points to each one to help you select the correct level of the MDM:

• Number of possible diagnoses and/or management options that must be considered
• Amount and/or complexity of the medical records, diagnostic tests, and/or other data to be obtained, reviewed, and analyzed
• Risk of significant complications, morbidity, and/or mortality as well as comorbidities, associated with the patient’s presenting problem(s), the diagnostic procedure(s), and/or the possible management options

Assigning points to each one of the components and tallying them can help you assess the MDM complexity level (e.g. straightforward, low, moderate, or high), which may also help in assessing the level of E/M code to report for the encounter. You must meet two of the three needs in the above bullets in order to be considered toward the level of service. However, most experts in E/M will recommend that MDM must be one of the three elements in determining the level of E/M code assignment (in other words, do not code higher than MDM).