Pediatric Coding Alert

While handy, the levels of medical decision making (MDM) table in CPT^® is infamous for being subjective and sometimes confusing, even for seasoned evaluation and management (E/M) coders.

Because CPT^® rolled out the significant changes to the MDM table for outpatient coders in 2021, by the time they published the new table for inpatient coders in 2023, most pediatric coders were already up to speed with the new leveling guidelines. However, some new and existing verbiage pertaining to the Number and Complexity element is creating more questions for some coders than answers.

Acute: As of 2023, the Number and Complexity of Problems Addressed column includes “1 stable, acute illness” in the list of examples of low level MDM. “I often see coders assuming that ‘acute’ must equate ‘new,’ explains Jacob Swartzwelder, CPC, CRC, CIC, CEMC, AAPC Approved Instructor, managing director at Compliant Approach Partners, LLC in Las Vegas, NV, during his session “E/M Audits for Primary Care” at HEALTHCON Regional 2023 in Washington, DC. The condition does not have to be new. In fact, the CPT^® E/M guidelines define an acute, uncomplicated illness or injury as a “recent or new short-term problem with low risk of morbidity for which treatment is considered.” Thus, you can safely interpret “acute” to include follow-up to an acute, uncomplicated injury or illness. “Just ensure treatment has previously been initiated and the condition is not fully resolved,” says Swartzwelder. Remember, you’re dealing with alignment with low overall MDM. “Generally, medically necessary follow-up for a resolved condition will align with straightforward overall MDM,” he continues.

Self-limited or minor: Coders are often confused by classifying patient conditions as “self-limited” or “minor.” Providers don’t use these words exclusively to describe patient problems, so when you’re considering the patient condition, think about whether it could have resolved on its own or could have been effectively treated at home without the physician. Examples might be a common cold or a minor injury like a small cut or bruise. From a CPT^® perspective, a self-limited or minor problem is one “that runs a definite and prescribed course, is transient in nature, and is not likely to permanently alter health status.”

Exacerbation: This term refers to a significant worsening, poor control, or escalation of a patient’s symptoms or conditions. The higher up in MDM level consideration, the more payers will be looking at your documentation to show exacerbation. “You can have a chronic illness with exacerbation, but if you don’t tell me the severity of the exacerbation in the documentation, I have to assume moderate. The treatment plan should correspond with the notes about severity of exacerbation,” said Swartzwelder. In other words, if your provider’s notes are not clear in this regard, use this as an opportunity for education at best, and a query at least.

Relax About the Amount and/or Complexity of Data

The Amount and/or Complexity of Data to Be Reviewed and Analyzed column is notorious for tripping coders up, and understandably so. Understanding the complexity of data often requires medical knowledge, which is why the provider’s documentation is so important. If the notes aren’t clear enough for you to accurately use this column to assign a level to the encounter, you should query the provider. However, if the information doesn’t affect the level, don’t let it derail you.

For example, let’s say that based on problems addressed and risk, you have a solid 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). Remember, you only need two out of the three elements, which means you can sometimes level the encounter without the data element. “I wouldn’t spend time calculating data unless it was going to mean the difference between one level and another that was medically necessary,” advised Rae Jimenez, CPC, CDEO, CIC, CPB, CPMA, CPPM, CCS, senior vice president of products at AAPC in her presentation “2021 E/M Lessons Learned,” at HEALTHCON 2022.

That’s not to say you should overlook opportunities for provider education when it comes to the data element. However, try to separate that from the information that’s truly needed to accurately level an encounter. “I see coders and auditors playing the ‘well, if’ game. Well, if the chronic condition was severe, and these labs were not billed separately, it would be high MDM. ‘Well, if’ is an efficient way to discuss the data element and educate providers, but inefficient for coding,” says Swartzwelder.

Expert tip: “Zoom out to see the larger picture. The entire encounter should flow and be consistent with the level of service selected. No element of MDM should drastically alter the overall level of service,” explains Swartzwelder.

Remember That Risk of Complications Refers to the Plan

Similar to the Data element, the Risk element is multifaceted. The important thing to remember is that the word “risk” refers to the treatment plan, not the patient.

For example, let’s say a child with documented asthma comes in for a routine check-up. The physician confirms the asthma is well-controlled with the current treatment plan, which includes a daily inhaled corticosteroid and a rescue inhaler for emergencies. Asthma is a serious condition, but risk as it applies to leveling relates to the treatment plan, which presents a low risk in this situation. However, if the same child had a severe allergy to the inhaler, this would complicate the treatment and require the physician to find alternative management. This would raise the risk element to a higher level.

Consider what the CPT^® E/M guidelines state:

“The assessment of the level of risk is affected by the nature of the event under consideration. For example, a low probability of death may be high risk, whereas a high chance of a minor, self-limited adverse effect of treatment may be low risk. Definitions of risk are based upon the usual behavior and thought processes of a physician or other qualified health care professional in the same specialty.”

In other words, the clinician defines the risk of complication or morbidity based on the circumstances, and while quantification is not necessarily required, you may want to establish an ongoing dialogue with the provider so you can better understand their thought process. If the provider doesn’t clearly indicate level of risk, without clarification you should default to the lowest level to avoid a compliance risk.

Stay tuned to future issues of Pediatric Coding Alert, as we dive into how to set up a solid clinical documentation improvement (CDI) process to support your clinic’s E/M coding.