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Part B Insider (Multispecialty) Coding Alert

Part B Coding Coach:

Accurately Score Medical Decision Making To Maximize Reimbursement For Your E/M Claims

Published on Thu May 12, 2005

Hint: Assign 2 points for reading radiology results

If you're having trouble making decisions about medical decision making (MDM), you're not alone. Undercoding E/M claims is a common physician blunder that can take a serious blow to your bottom line.

Medical decision making is only one of the three key E/M components, but it's considered the most complex, and most often inaccurately assessed, component. Study these E/M examples to help you master scoring MDM - and win big in the E/M claims arena.

Break Down The Decision Making

The key to determining MDM is to understand that each of the three components receives a score of 0-4+ points, with the total number of points determining the level of each component. Two of the three components must be at the same or higher level in order to establish the level of medical
decision making.

CPT Codes provides the following scoring scale for MDM: See chart at right.

Example: If the number of diagnoses is limited, but the data and risk are moderate, you would disregard the diagnosis element and assign an MDM of "moderate" based on the other two levels.

Take Note: Although common, not every carrier uses this point system. Check with your carrier as to what system they use to quantify this information.

Number The Patient's Problems

The first step to determining your MDM level is figuring out the number of diagnoses and management options. When assessing this level, you should ask 1) What is wrong with the patient and 2) How many diagnoses are there? Score the category as follows:

1 pt = minimal
2 pts = limited
3 pts = multiple
4 + pts = extensive

For a chart to help you score diagnoses and management options, e-mail Livia Levis at livial@eliresearch.com.

Example: An established patient comes in complaining of increasingly frequent nosebleeds. Assign one point for the nosebleed (a minor problem that is worsening), which the physician determines is the result of insufficient humidity in their apartment and suggests a humidifier to help resolve the problem. This results in a diagnosis/management level of "minimal."

Add Up The Amount of Data

The second component, amount and/or complexity of data to be reviewed, scores in a similar manner: minimal (0-1), low (2), moderate (3), and high (4+). You should assign one point per class of data. The classes are as follows:

  •  Review/order clinical labs
  •  Review/order radiology
  •  Review and/or order of tests/procedures in the medicine section
  •  Discuss diagnostic test results with the test-performing physician
  •  Independent review of image, tracing, or specimen (not simply review or report)
  •  Decision to obtain old records/obtain history from someone other than patient

  •  Review and summarize old patient records

    When scoring, it's important to know that not all of these classes have a score of one point. The review and summary of old records and the independent review of image both have 2 points assigned to them.

    Tip: You receive a point when you order a test, and you receive a point again when you review the test results at the next visit, notes Barbara J. Cobuzzi, CPC, CPC-H, CHBME, president of Phoenix Healthcare Solutions in Brick, NJ. This "double dipping" only works if you order and review in separate sessions. You may not receive double points if your order and review in the same session, she cautions.

    Beware: Never assign points for each lab test or each x-ray. All tests within a class are considered as a group. Ordering and interpreting 5 x-rays will still only earn you 1 point for ordering and 1 point for reviewing the x-rays at the next visit.

    Get Paid For Reading A Film: Physicians often want to know how to bill for interpreting the x-ray films their patients bring to the office. You can't bill reading as the professional component, says Cobuzzi, as the radiologist has already billed that. But what you can do is report the film review as an "independent visualization" and collect 2 points for the MDM data section, she explains.

    Example: A patient presents with a swollen, bruised, and lacerated finger that he caught in a closing truck door three days earlier. Suspecting the finger is both broken and infected, the physician orders x-rays and a labs to check to see if there is indeed an infection. He reviews the results that day and determines that while not broken, the finger is infected. Score: Two points, one for ordering and interpreting the labs, and one for ordering and interpreting the finger x-ray. You should therefore assign a data complexity level of "low."

    Calculate The Risk

    Level of risk, the third component of MDM, can be the most difficult part to determine because it is the most complicated. Unlike with the other two components, you determine a patient's level of risk by selecting the highest score (minimal, low, moderate, or high) of the component's three categories: presenting problem, diagnostic procedures ordered, and management options. CMS's 1995 guidelines for MDM have a "Table of Risk" with examples of each of the three categories (see www.cms.hhs.gov/medlearn/1995dg.pdf)

    Example: A female patient suffering from hypertension and diabetes comes in complaining of frequent hypoglycemic attacks. The physician draws blood for a full workup and changes her insulin protocol.

    Assess the Risk: According to the Table of Risk, a patient with one or more chronic illnesses with mild exacerbation falls under "moderate" in the "presenting problems" category. You should assign "minimal" to the diagnostic procedure because the physician only orders and reviews the bloodwork.

    Prescription drug management, such as writing a prescription, is considered moderate risk in the table, notes Laureen Jandroep, OTR, CPC, CCS-P, CPC-H, CCS, senior instructor and director at the CRN Institute.  Since the physician changes the patient's insulin protocol in this case, the management options category receives a "moderate" level of risk.

    Final Score: You should select the highest of the three to determine level of risk, says Jandroep. In this case, the highest level of risk is "moderate" because of the prescription drug management and the patient's presenting problems.

    See The Big Picture

    Once you understand how to score the three components, you can easily put them all together and determine the physician's MDM. Study this example and see if you can determine the MDM by assessing all three components.

    Example: A patient comes in with migraine headaches and the physician writes them a prescription for Midrin.

    Final  MDM Score: You should select "straightforward."

  • Rationale: There is only one diagnosis, the migraine, (minimal), there is no data to review (minimal), and the level of risk is "moderate" because of the prescription drug management. However, two of the three levels of MDM must be met or exceeded. With two scores of "minimal" you must assign an MDM level of straightforward.

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