Orthopedic Coding Alert

E/M FAQ:

Use This FAQ to Conquer MDM Questions

Published on Mon Dec 06, 2021

Check out this advice on how to tally number and complexity of problems.

OK, we’ve all had a nearly a year of real-world practice reporting office/outpatient evaluation and management (E/M) services based on medical decision making (MDM).

But still, questions remain regarding how to use MDM to select the best E/M code level for your office/outpatient visit.

Help’s here: We got some experts to guide you through the most pressing MDM issues with this FAQ when deciding how to report 99202 (Office or other outpatient visit for the evaluation and management of a new patient, which requires a medically appropriate history and/or examination and straightforward medical decision making. When using time for code selection, 15-29 minutes of total time is spent on the date of the encounter.) through 99215 (Office or other outpatient visit for the evaluation and management of an established patient, which requires a medically appropriate history and/or examination and high level of medical decision making. When using time for code selection, 40-54 minutes of total time is spent on the date of the encounter.).

Zero in on Necessary MDM Elements

Question 1: Must we document all three MDM elements when choosing an office E/M code not based on time?

Answer 1: No, you don’t have to document all three MDM elements. Two out of three elements can dictate MDM level, according to Terri Brame Joy, MBA, CPC, COC, CGSC, CPC-I, billing specialty subject matter expert at Kareo in Irvine, California.

The confusion on this point may stem from the fact that the MDM table includes the following three elements that can help you select the MDM level:

Number and complexity of problems addressed
Amount and/or complexity of data to be reviewed and analyzed
Risk of complications and/or morbidity or mortality of patient management

If you’re poring over charts and reports trying to pinpoint an MDM level because you want to meet all three criteria, keep in mind that you must only meet two of the three to justify a particular MDM level, according to CPT^®guidelines.

“This means that if one area is weak, we are able to drop it,” says Barbara J. Cobuzzi, MBA, CPC, COC, CPC-P, CPC-I, CENTC, CPCO, CMCS, of CRN Healthcare in Tinton Falls, New Jersey.

Tip: You might want to avoid using amount and/or complexity of data as one of the two MDM elements in many cases. “Counting the data elements can be a challenge. There are a lot of variables that you can have arguments with payers about in terms of collection of data,” Cobuzzi says.

Instead: “It’s my recommendation that, when possible, you concentrate on the number and complexity of problems being addressed during your encounter … and then also focus on the risk of complications and morbidity or mortality of patient management,” Cobuzzi says.

Make ‘Problem’ a Focus

Question 2: What exactly counts as a “problem,” and should I count all problems, or just the specific problem the physician is addressing at the encounter?

Answer 2: “A problem is a disease, condition, illness, injury, symptom, sign, finding, complaint, or other matter addressed at the encounter, with or without a diagnosis being established at the time of the encounter,” according to CPT^®guidelines.

Count them all: Even though you’re ultimately going to assign just one diagnosis to the patient’s claim for the visit, you should count each problem addressed. If your provider sees a patient with a high number of differential diagnoses, you should list them all to justify MDM, according to Brame Joy.

Symptoms, too: A patient may present with a sign or symptom for which the clinician doesn’t establish a diagnosis during that visit. “However, evaluating it still adds complexity to that visit,” Cobuzzi says, so you should still count it as a problem in the MDM.

For example: A patient may come to the office for a fracture that isn’t healing. If the physician documents swelling at the fracture site and a fever, plus that the patient has diabetes, each of those findings contributes to the number and complexity of problems addressed during the encounter.

Question 3: Is counting the problems enough, or must the documentation show how the physician addresses the problem(s)?

Answer 3: The point of documenting all the problems addressed by the physician during a visit is to make sure a payer would be able to visualize the thought process they used while analyzing a patient’s problems and managing them, according to Cobuzzi.

Advice to physicians: “You want to think and ink,” Cobuzzi says. “Take everything you’re thinking and record it as part of the medical decision making.”

Record Treatment Goals

Question 4: How do we establish if a patient’s condition is “unstable,” which qualifies it as moderate rather than low complexity?

Answer 4: This is an important concept, because an unstable condition qualifies as moderate rather than low complexity, which might qualify the encounter for level 4 rather than level 3.

The MDM table refers to “stable, chronic illnesses.” The concept of a chronic condition is fairly straightforward: one that is expected to last at least one year or until the patient’s death. But “stable” can be more challenging to evaluate.

Key: “Stable means that the patient is at their specific treatment goals,” Cobuzzi says. That means your provider should include documentation of those goals.

Tip: If you add a “treatment goal” line to your templates for patients with a chronic illness, that reminds the physician to document goals and whether they’ve been met.

Guidelines: CPT^®states, “A patient who is not at his or her treatment goal is not stable, even if the condition has not changed and there is no short-term threat to life or function.”

Resource: To review the AMA’s MDM chart, visit https:// www.ama-assn.org/system/files/2019-06/cpt-revised-mdm-grid.pdf.