Part B Insider (Multispecialty) Coding Alert

Complex decisions aren't always the deciding factor

Myth: You must always include medical decision-making (MDM) as one of the two elements (out of three) that you use to set the level of an established patient visit.

Fact: You can use any two out of the three elements of an evaluation & management visit: history, physical examination or MDM, says Joan Gilhooly with Medical Business Resources in Evanston, IL.

People often become confused because Medicare requires each E/M level to be -medically necessary,- says Gilhooly. -People try to equate medical necessity with medical decision-making,- she says, but they-re -like two different ends of the horse.-

Medical necessity is closer to the concept of the -nature of the presenting problem.- It's the problem that brings the patient to your doctor's office, before the doctor even starts gathering information and examining the patient.

MDM, by contrast, is what the doctor decides to do after gathering information.

On the safe side: Coders have a -pervasive feeling- that MDM should be one of the two elements that decides your E/M code level, says consultant Jean Stoner with CodeRyte in Bethesda, MD. Nobody has ever put this requirement into writing, but coders worry that auditors will use this as a rule. They may base the E/M level on the MDM and one other element just to be -conservative,- Stoner says.

With doctors who provide lots and lots of documentation of history and physical exam, even in patients with fairly basic problems, it may make sense to insist that the MDM justify the E/M level, Gilhooly notes. But in some cases, a patient may have a problem that justifies a higher level of E/M claim, based on the history and physical exam, she adds.

For example: A patient comes in with recurring abdominal pain, and the doctor has treated it before. The abdominal pain hasn't responded to treatment, and has either stayed the same or worsened. The doctor orders a CAT scan. This represents a fairly simple MDM, but -abdominal pain could actually be something very significant,- says Gilhooly. The doctor may have to ask many questions and perform a comprehensive examination to rule out various diagnoses.

Also, relying on MDM isn't always the most conservative approach, Gilhooly insists. Sometimes the MDM component could skew the E/M level too high.

For example: An established patient comes in with an upper respiratory infection, which is a new problem. The doctor prescribes an antibiotic. -That's not a moderately complex problem,- Gilhooly says. But the fact that it's a new problem and the doctor prescribes medication could lead to an unrealistically high level. -It puts the practice at risk- to rely on the MDM component in every instance, she says.

But even if you have a more complex MDM, you still would need a history or exam to justify a higher level code, notes Stoner.