Pediatric Coding Alert

Hint: The "if this, then that" notes are key when determining level of risk.

Selecting the appropriate level of service for an evaluation and management encounter, such as an office visit, leads most providers to determine that the medical decision making (MDM) complexity is the most complicated and difficult piece of the puzzle. But if calculating has you scratching your head, you aren't alone.

To determine the level of MDM, you should assign points to each of the three MDM components that your physician performs. The number of points in each category determines the final MDM level. There are three elements that contribute to the complexity of your medical decision making. "The elements are diagnoses/management options, complexity of data reviewed/ordered, and the table of risk," says Suzan Berman, CPC, CEMC, CEDC, Senior Director of Physician Services at Healthcare Revenue Assurance Associates based out of Plantation, Florida.

You must have two out of the three MDM components score at a particular level in order to assign that level of MDM. For example, if the number of diagnoses is low, but the amount and complexity of data and level of risk are both moderate, your MDM score is moderate. An alternative method to determine the correct level of MDM is to eliminate the highest and lowest scores, and the remaining score is the level for the particular MDM in question.

Follow this three step process to determine each component level.

1. Understand Each Level of Diagnosis

Start your MDM level assessment by tackling the first category: number of diagnoses. For this category, ask, "What is wrong with the patient?" and "What is the total number of medical diagnoses that the patient has that the doctor addressed during the encounter?"

For each diagnosis, you will assign a point and score the diagnosis level as follows, says Chandra L Hines, practice supervisor of Wake Specialty Physicians in Raleigh, NC:

• Self-limited/minor problem -- 1 point each, with a max of 2 points
• Established problem, improving/stable -- 1 point each
• Established, worsening -- 2 points each
• New problem, no planned additional workup -- 3 points each, max of 3 pts
• New problem, additional workup -- 4 points each

Use a worksheet to determine the point value to assign. "The point system has been adopted by most insurance carriers; however, it is officially the 'Marshfield system,'" Berman explains. "Trailblazers, for example use a different point structure."

Example: A two-year-old girl presents with fever to 103 and vomiting once each day for two days. She has also had a cold for three to four days. She is lethargic and dry. She has a slight cough, is eating poorly, but taking fluids fairly well. There are no rashes, joint swelling, and no diarrhea. She is urinating frequently and appears to cry when voiding. She has been healthy in general and does not have a history of ear infections. There are others ill at home with colds. A bagged urinalysis is positive for nitrites. A cathed urine is obtained, also nitrite-positive with 23 to 30 WBCs per high power fields. Her urine is sent to the lab for culture and sensitivity. A diagnosis of urinary tract infection (599.0) with comorbidity with fever is made. She is treated with an injection of IM Rocephin, with follow-up scheduled the next day. An extensive discussion takes place regarding her diagnosis, treatment (including managing fluids), and fever, and the need for follow-up.

Score: In this example, with one new diagnosis and two minor other diagnoses with additional workup ordered for one of them, you would assign "high" as the diagnosis level.

2. Classify Your Data Complexity

The second component to consider when deciding on your MDM complexity is the amount and complexity of the encounter's data. For this piece of the MDM puzzle, you need to determine if your work included the following classes of data:

• Review/order of clinical lab services such as WBC or PSA tests (80000 codes)
• Review/order of radiology services such as x-rays (70000 codes)
• Review/order of medicine services such as an EKG (90000 codes)
• Discuss results with test-performing physician
• Independent review of image, tracing or specimen, such as such as reading a renal sonogram or CT scan brought in by the patient to the office visit
• Decision to obtain old records/ obtain history from someone other than patient
• Review and summarize old patient records from an outside source.

You will score the complexity of data in the same manner as the diagnoses: minimal (0-1), low/limited (2), moderate (3), and high (4+). Review the worksheet on page 70 for details.

Remember: No matter how many x-rays or labs your physician orders, you can only assign one point for ordering and reviewing all of the data in each of those two classes. "In the Marshfield system, you can also get 2 additional points for independently visualizing," Berman states. "However, a maximum of 2 points is permitted for such activity."

Score: In the above example, you would assign two points: one for the catheterized specimen order and one for the culture ordered. The level of amount and complexity of data is therefore "low/limited."

3. Weigh the Risk

The final of the three MDM categories, level of risk, can be the most difficult part to determine. "This is the most confusing component of the MDM section," Berman says. "We really need to be in tune with our physicians and the diseases processes for which we code. This helps. It also helps when the physician is thorough and complete in the documentation so that we can determine patient specific risks, therapies ordered, etc."

Level of risk involves three subcategories: presenting problem, diagnostic procedures ordered, and management options. Comorbidities, the need for diagnostic testing, the plan of care, and so on, may complicate the medical decision making, Hines explains. The highest score from only one of the three categories (not from each category) determines the patient's risk level, minimal, low, moderate, or high.

Learn more: The Centers for Medicare and Medicaid Services' 1995 and 1997 guidelines for MDM contain a "Table of Risk" with examples of what constitutes each level of the three subcategories. View the "Table or Risk" online on page 15 of the 1995 E/M Guidelines (https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNEdWebGuide/Downloads/95Docguidelines.pdf) or page 47 of the 1997 Guidelines (https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNEdWebGuide/Downloads/97Docguidelines.pdf).

For the earlier example, when you look at the table of risk, the patient has one new acute complicated illness (UTI with fever) and one minor illness (URI), which combine for a moderate risk level for the presenting problems column.

Future planning pointer: Physicians should clearly indicate when they're taking an intermediate step that they don't believe will solve the patient's problem. For example, they may try antibiotics before a more aggressive treatment, says Marcella Bucknam, CPC, CPC-I, CCS-P, CPC-H, CCS, CPC-P, COBGC, CCC, audit manager for CHAN Healthcare in Vancouver, Wash.

"Explaining that they're trying the more conservative treatment, but that the patient may require a more aggressive approach, can boost the level of MDM," she adds. "Documenting the extra step shows that the physician considered more management options (one element of MDM)."

Don't get emotional: Keep in mind that E/M codes aren't based on the patient's general health. Don't code a higher level of decision-making than the documentation supports. Often, providers and coders will boost the MDM because they know the patient is really sick. But you have to code based on what is documented and nothing more.

Final MDM: In the example we have been using throughout this article, the physician performed an E/M service with moderate level presenting problems, moderate data amount and complexity, and moderate risk. With two of the three MDM components scoring moderate or higher, you have moderate complexity MDM. If we assume that the history and exam are detailed, you should assign an E/M level of 99203 for a new patient or 99214 for an established patient.