Otolaryngology Coding Alert

You can nail down all the score sheet's fundamentals, but if you can't sort out low from moderate risk, you could end up under- or overcoding your ENT's MDM.

In Otolaryngology Coding Alert 2008, Vol. 10, No. 3, we walked you through the audit tallying basics. See if you-ve got what it takes to score the following case's medical decision-making (MDM) using the standard CMS form.

You code it: An ENT sees a patient with a diagnosis of otitis media (OM) and decides the patient requires tubes. The physician orders no tests and reviews no records. The patient is scheduled for tympanostomy (69436, Tympanostomy [requiring insertion of ventilating tube], general anesthesia).

In the table for number of diagnoses or treatment options, you must identify the problem's status. Do so following these rules:

- If the ENT has previously treated the patient for OM, CMS considers the problem established and awards two points for an established problem that is inadequately controlled, worsening or failing to progress as expected.

- If this is the first time the ENT is treating the patient for OM, you should consider the diagnosis a new problem, which is worth three points.

Why is there a point difference? CMS expects "that the decision-making for a known problem is less than that of a new problem," says Susan Callaway, CPC, CCS-P, an independent coding auditor and trainer in North Augusta, S.C.

Now, let's tally the amount and/or complexity of data reviewed using that table.

This one is fairly simple. Because the ENT did not review any data, he receives a zero in this table.

Now, on to the difficult part. Let's determine the scenario's level of risk (minimal, low, moderate or high).

Here's how: You select the risk level based on the single highest element identified in the table of risk's three columns (1 of 3). You do not need one element in each column. You instead assign the patient's risk using one element in the one column that represents the highest level. To get started, classify the level of these elements:

- presenting problem(s)

- diagnostic procedures ordered

- management options selected.

Should you classify OM with a decision for tubes as a presenting problem that is stable chronic (low), acute uncomplicated illness (low), or acute illness with systemic symptoms (moderate)? "You will get different opinions on it," says Hayes H. Wanamaker, MD, chief of otolaryngology at Crouse Hospital in Syracuse, N.Y.

To get to the heart of the matter, look for more details. The history that the staff and otolaryngologist documented will be important, Wanamaker says. "If there is documented hearing loss, balance dysfunction, speech/language delay, tympanic membrane rupture, you could argue that it represents an acute or chronic illness that may pose a risk to loss of function, classifying the presenting problem as high."

Although documentation might sometimes support a high presenting problem, you-ll probably be above low for OM leading to tympanostomy (69436). In most cases, the risk would be at least moderate falling under either chronic illness with progression, or acute illness with systemic symptoms, Wanamaker says.

To calculate the diagnostic procedures level, you-ll focus on any workup the otolaryngologist ordered. Because the physician in the OM case study did not order any diagnostic procedures, you have no circle in column two.

When you scan down the options in category three, you may hesitate regarding whether to count tube placement as a minor or major surgery. "Realistically, a tube placement is minor surgery, at least that is what most of us tell our patients," Wanamaker says. The table of risk classifies a minor surgery as low risk, assuming the patient is generally healthy without comorbidities. A risk factor, such as asthma, increases the table of risk value.

Best bet: Before selecting the management options level, check if the patient has any identified risk factors. "This refers to the patient's unique medical history that might affect the outcome," Callaway says. For instance, if the patient in our case has asthma, you would circle "minor surgery with identified risk factors," instead of "minor surgery with no identified risk factors," upping this category's level from low to moderate.

To judge the case's ultimate risk level, look at your three circles. Let's say in our OM case, the physician's diagnosis of chronic otitis media with effusion 381.3 (Other and unspecified chronic nonsuppurative otitis media) and documentation support a chronic illness with progression, and the child who is new to the ENT has no comorbidities. Therefore, you have these levels:

Do your circles equate to low or moderate risk? "You only need the one item for risk," Callaway says. Assign the level based on the highest circle.

As the above chart shows, the highest level you circled is moderate. Therefore, the OM case has a moderate risk level.

Breathe a sigh of relief. You-re at the final MDM calculation step. To tally your whole MDM, enter the three tables- scores in the Final Result for Complexity table. Determine the final score using two out of the three elements (2 of 3). You circle a "3" in the first row for a new patient with a worsening condition, "moderate" for the highest level of risk, and "< 1 Minimal" in the third row for no work-up ordered as follows:

Tally: Because the scenario involves two circles in one column, you draw a line down that column, which classifies the case as moderate complexity. This level of medical decision-making can support a level-four new patient office visit (99204, Office or other outpatient visit for the evaluation and management of a new patient, which requires these three key components: a comprehensive history, a comprehensive examination and medical decision-making of moderate complexity).

Before you rush to code a level-four new patient visit, make sure you consider the rest of the documented visit. The medical decision-making portion is one factor in assigning the E/M level, Wanamaker says. "You would need the corresponding history and physical exam information to support" the chosen code's level, Wanamaker says.

In OM cases, expect mainly level-threes with occasional fours. "Realistically, it would probably not be appropriate to code a level-five except in extremely unusual circumstances," Wanamaker says. Insurers may scrutinize a pattern of coding level-four visits for OM patients, he adds.