If you've been downcoding to a level-four office visit or lower just to play it safe, you may be missing out on some well-deserved reimbursement. Established Patient E/M Level Takes 2 out of 3 You should use three components to determine the level of E/M service to report. These include the history taken at the time of visit, the extent of physical examination, and medical decision-making (MDM). For office or other outpatient visits for established patients, you must meet two of the three criteria in order to bill for a specific level of care. New patients require three out of the three criteria. Risk Element Can Ensure Pay Determining the level of risk can be the hardest of the three components, since it requires more than just counting diagnosis options or lab tests ordered. According to Catherine Brink, CMM, CPC, president of Healthcare Resource Management of Spring Lake, N.J., this category includes risks associated with the presenting problems, the diagnostic procedures, and the management options. The highest level of risk in any of these areas determines the overall risk. Add Diagnostic Options to the Mix Although determining the level of risk may be the most difficult for you, the number of diagnoses and treatment options should not be overlooked. According to CMS guidelines, the number of possible diagnoses and management options that must be considered is based on the number and types of problems addressed during the encounter, the complexity of establishing a diagnosis, and the management decisions made by the physician. Document Complexity of Data The physician needs to document the tests performed, tests reviewed, and past medical records reviewed, Brink says. If it is not documented, you cannot count it toward the complexity-of-data category of MDM. According to CMS, the amount and complexity of data to be reviewed is based on the types of diagnostic testing ordered and reviewed. The decision to obtain and review old medical records and the discussion of test results with the physician who performed or interpreted the tests are also indicators of the complexity of data to be reviewed. Clear Up Confusion With Case Studies Considering the myriad information you have to assimilate to determine the level of MDM, you should take a look at the following examples provided by Raequell Duran, president of Practice Solutions based in Santa Barbara, Calif: It is important to remember that the examples above represent only one portion of medical decision-making: overall risk. The number of presenting problems and data reviewed must be determined along with the overall risk to determine the type of MDM. (The above examples are not intended to be vignettes and are not approved or sanctioned by Medicare or the AMA.)
Facing CMS scrutiny of high-level office visit coding and complicated coding guidelines, many practices shy away from reporting 99215 for physician services to escape possible audits. You can avoid this problem by learning some clear-cut rules regarding criteria for high-level E/M visits. Assuming your physician's services adequately qualify for a higher-level E/M code, you could see a reimbursement difference of around $30 or $35 as you move up the scale from 99213 to 99215.
In October, we told you how to ensure that your his-tory levels made the cut for high-level E/M codes. Now, we'll concentrate on medical decision-making (MDM).
Most coders find the MDM piece of the puzzle difficult to fit into place. Determining the difference between straightforward (S), low (L), moderate (M), and high (H) MDM can be an arduous task. Select the MDM level by looking at three aspects of the visit:
Take the four levels of risk as examples:
Management options include elective major surgery with risk factors, emergency major surgery, parenteral-controlled substances, drug therapy requiring intensive monitoring for toxicity, and the decision not to resuscitate or to de-escalate care because of poor prognosis.
You must document an assessment, clinical impression, or diagnosis for each encounter, along with the initiation or change in treatment and any consultations or referrals initiated. For a presenting problem with an established diagnosis, document whether the problem is
(1) improved, well controlled, resolving, or resolved or
(2) inadequately controlled, worsening, or failing to change as expected. You can use the number and types of diagnostic tests employed as an indicator of the number of possible diagnoses.