Podiatry Coding & Billing Alert

E/M Coding:

Strengthen Your MDM Savvy With These 5 Podiatry Scenarios

Published on Wed May 17, 2023

Here’s how to juggle the elements for optimal results.

Assigning a medical decision making (MDM) level to evaluation and management (E/M) claims can give even the most seasoned coder a headache — but it doesn’t have to. If you remember a few essential tips and master podiatry-specific MDM examples, you can become a master in no time.

Know the 3 MDM Elements

Two years ago, coders faced the CPT^®overhaul of codes 99202-99205 (Office or other outpatient visit for the evaluation and management of a new patient …) and 99212-99215 (Office or other outpatient visit for the evaluation and management of an established patient …). Ever since then, you’ve been basing your outpatient E/M code selection either on time or on MDM.

MDM can be challenging for coders because it requires you to assess three separate elements:

Number and complexity of problems addressed (minimal, low, moderate, high)
Amount and/or complexity of data to be reviewed/ analyzed (minimal, limited, moderate, extensive)
Risk of complications and/or morbidity or mortality (minimal, low, moderate, high).

Many podiatry coders trip on MDM and downcode their claims as a result, but as long as you meet two out of the three MDM components, you can assign that level of MDM and pick the corresponding E/M code.

Example: Suppose your podiatrist sees a patient who was referred by the local hospital, where they went to the emergency department recently for unexplained left foot swelling, followed by a referral to your office. When the podiatrist completes the documentation, the number of diagnoses is low, but the amount and complexity of data and level of risk are both moderate. In this case, because you met two out of three components, your MDM score is moderate.

A moderate MDM level supports 99204/99214 (Office or other outpatient visit for the evaluation and management of a/an new/established patient, which requires a … moderate level of medical decision making …).

Tally the Problems Addressed

Some coders struggle with MDM because they don’t quite understand the first category: number and complexity of problems addressed. For this category, ask, “What is wrong with the patient?” and “How many medical diagnoses does the patient have, and how complex are they?”

Example: A diabetes patient presents to your podiatrist complaining of toe pain. The podiatrist examines the patient and discovers that their diabetes has led to ulcers between the patient’s first two toes. The patient says they have never had foot ulcers before. In this situation, the patient has one chronic illness (diabetes) with an exacerbation or progression (the ulcers), which means you can count it as a moderate level of number and complexity of problems addressed.

Classify Your Data Complexity

Once you’ve calculated the number and complexity of problems that the podiatrist addressed, you’ll move on to the next category: Amount and/or complexity of data to be reviewed and analyzed.

Look through the record to evaluate which types of analyses and reviews the podiatrist had to undertake. Did they order new tests, review previous ones, talk to other providers, review other providers’ records, interpret tests, or discuss test interpretations with other clinicians? Take all of these factors into consideration when selecting the level in this category.

Example: A 14-year-old patient who just got back from vacation presents with an infected cut on the plantar surface of their foot that they sustained when they slipped and landed on jagged shore rocks at the beach. They also complain of severe pain in a different region from the laceration.

The podiatrist orders and reviews new lab work and X-rays. They also review the patient’s records from the doctor they visited during the beach trip. The level of amount and complexity of data is therefore moderate.

Remember: Per AMA guidelines, if your provider orders a test for which you report a separate CPT^®code, you cannot count the test toward MDM levelling. “You don’t want to double dip,” cautions Leonta “Lee” Williams, MBA, RHIA, CCS, CCDS, CPC, CPCO, CRC, CEMC, CHONC, AAPC’s director of education and a healthcare management consultant for Karna, LLC.

However, if an outside source orders and bills for the test, but your podiatrist reviews it, you can count the review as a data point for your levelling calculations.

Determine the Risk

The final of the three MDM categories, level of risk, can be the most difficult part to determine.

That’s because risk is determined not by the specific treatment the provider recommends, but by the thought process the provider undergoes to arrive at the decision of whether or not to treat the patient and by the positive or negative effect a particular treatment may have on a patient’s condition. So, a treatment or surgery considered for a patient could count as a moderate- or high-risk element for MDM whether or not the provider or the patient decided to follow through with it.

Example: The patient presents complaining of toe pain. The podiatrist evaluates the patient and notices that they have a healing wound on their great toe. They ask the patient for more information, and the patient reveals that they thought they had an ingrown toenail, so they picked at the toe and applied ointment and a bandage, but that it still hurts. The podiatrist determines that the toe is only sore due to the healing wound, and that it’s not infected, requiring no further intervention. In this case, the risk is low.

Putting It all Together

Once you know how to evaluate each MDM category, you can select the overall MDM level.

Example: A 16-year-old established patient complains of pain in their right hallux valgus. The pain is constant and throbbing, and has been for three days. The podiatrist examines the toe, diagnosing the patient with an ingrown toenail that will require surgery.

Breakdown: You have one diagnosis: an ingrown toenail. This means the level for number and complexity of problems is minimal.

The podiatrist reviewed a note from the patient’s primary care provider (PCP) and reviewed the PCP’s X-ray, then ordered blood work to determine if the patient had an infection. This leads to a moderate amount of data to be reviewed/analyzed.

For level of risk, the patient will require minor surgery, which leads to a moderate risk level.

Final MDM: With two of the three MDM components scoring moderate, you can report 99214 for this established patient.

Don’t Forget Definitions

When trying to calculate the level of MDM for a particular encounter, you should avoid the temptation of simply using the MDM table to assign an office/outpatient E/M code. “Many people go right to the MDM grid and miss all the important information in the guidelines, including the definitions, that precede it,” notes Rae Jimenez, CPC, CDEO, CIC, CPB, CPMA, CPPM, CCS, senior vice president of products at AAPC and member of the CPT^®Editorial Panel.

Torrey Kim, Contributing Writer, Raleigh, N.C.