Ophthalmology and Optometry Coding Alert

The medical decision-making component of an E/M service straightforward, low, moderate or high is determined based on 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; and the level of risk of significant complications, morbidity and/or mortality including comorbidities associated with the patient's presenting problem(s), diagnostic procedure(s) and/or the possible management options.

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

In the category of presenting problems, if the patient is established and is seen for a return visit and has stable glaucoma and no other documented problems, the patient is considered to have minimal problems. The minimal category represents patients who present with one established problem that is either stable or improving.

But if, for example, a patient returns with uncontrolled glaucoma that requires a change of medication, the level of problem is bumped up to low, and this increases your chances of being able to bill a higher-level E/M service. Uncontrolled glaucoma meets the requirements of low risk because it is an established problem that is worsening or failing to improve as expected.

And, if the patient was a new patient, the presenting problem would be considered moderate, as one new problem with no additional workup planned.

The second category, data review, determines the extent of data the physician orders and/or reviews. With the typical glaucoma patient, the level of data review will typically be considered minimal, for either no review or ordering of testing services, or the order or review of a test from the medicine section of CPT-4.

Last, you have to determine the risk associated with the patient's presenting problems, the diagnostic services ordered and any selected management options. If the patient has controlled glaucoma, the presenting problem is considered low because the patient has only one chronic illness and a minimal to low level of diagnostic tests is required. If the patient with controlled glaucoma is on prescription medication, the management option would be considered moderate. In this category, as stated above, the highest factor of either presenting problems, diagnostic testing or management options determines the level of risk, so in this example the risk would be moderate.

All three categories must then be compared to find the type of medical decision-making (MDM):

 

In the example of the established patient with stable glaucoma, the type of MDM would be straightforward. In the example of the established patient with worsening or failing-to-improve glaucoma, the type of MDM would be low complexity, and the new patient example would be moderate complexity.

The directions from the Medicare audit form instruct you to "draw a line down any column with 2 or 3 circles and circle the level of decision-making in that column. Otherwise, draw a line down the column with the 2nd circle from the left."