Podiatry Coding & Billing Alert

Here’s how to take clinician thought process and judgment into account.

In Podiatry Coding & Billing Alert volume 14, number 10, we discussed how the amount and/or complexity of data to be reviewed and analyzed element of medical decision making (MDM) factors into calculating evaluation and management (E/M) level calculations. This month, we’ll take a look at another MDM element that is often misunderstood — the risk of complications and/or morbidity or mortality of patient management element.

To help you understand it better, here are five hints to help you decide if you want to use the risk element to calculate an E/M level and the best way to do so.

Hint 1: Understand What Risk Really Means, and How It Relates to MDM Levels

The CPT^® E/M Services Guidelines provide several definitions that you should apply when determining the risk level of an office/outpatient E/M service:

• Risk is “based upon the usual behavior and thought processes of a physician or other qualified health care professional.”
• Risk is “based upon consequences of the problem(s) addressed at the encounter when appropriately treated.”
• Risk “includes MDM related to the need to initiate or forgo further testing, treatment and/or hospitalization.”

In other words, risk is determined not by the specific treatment the provider recommends, but by the thought process the provider undergoes to arrive at the decision 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.

Hint 2: Understand How to Determine Surgery Risk Level

CPT^® tells you that minor or major surgeries “are not defined by a surgical package classification,” so you cannot use global package information to determine risk for a particular procedure. Instead, as with any risk determination, the provider is the one who should make the eventual determination based on “risk factors … relevant to the patient and the procedure,” per CPT^® guidelines.

Again, this level is not dependent on the surgery actually being performed; if a provider recommends surgery and the patient decides against it or wants to put it off or get a second opinion, the risk level remains the same as it would if the surgery went ahead as planned. It is also important to note that both elective and emergent procedures can be classified as either minor or major. The terms simply describe the timing of a procedure as it relates to the patient’s condition.

Hint 3: Understand How to Calculate OTC Medication Risk

Over-the-counter (OTC) medication probably presents a low-risk MDM element, but under the right circumstance, it could rise to a moderate level. For example, OTC antifungals can make tyrosine kinase inhibitor (TKI) levels increase to an unsafe level in patients suffering from leukemia. If a provider factors the risks of using such OTC medications for a patient receiving TKI therapy into their MDM, then you can make a case for the risk element to rise to moderate for the encounter. However, the provider must document how these OTC medications may impact other ongoing therapy. If this is not documented, it may be missed upon coding/audit or questioned by the payer.

But remember: You should “ask, ‘do you need that information in order to support a higher level?’” suggests Rae Jimenez, CPC, CDEO, CIC, CPB, CPMA, CPPM, CCS, senior vice president of products at AAPC and member of the CPT^® Editorial Panel. As you have three MDM elements, and you need to meet or exceed two out of the three to arrive at the appropriate E/M level for the encounter, you always have the option of using the data and number of problems addressed elements in your E/M calculation if they better justify the medical necessity for the E/M level.

Hint 4: Understand How SDoH Factors Into Risk Level

Social determinants of health (SDoH) are “conditions in the environments in which people are born, live, learn, work, play, worship, and age that affect a wide range of health, functioning, and quality-of-life outcomes and risks.” They include such things as the “availability of resources to meet daily needs (e.g., safe housing and local food markets) … access to educational, economic, and job opportunities … access to health care services, quality of education … transportation options … social support … socioeconomic conditions … [and] language/ literacy,” according to the Office of Disease Prevention and Health Promotion (ODPHP) (www.healthypeople.gov/2020/topics-objectives/topic/social-determinants-of-health).

When your podiatrist notes that one or more of these things “significantly limits” a patient’s diagnosis or treatment (for example, a patient’s economic circumstances inhibit their ability to pay for treatment, or their lack of transportation affects their ability to attend appointments), then you can use the information to assign a moderate risk level of MDM of morbidity to the encounter.

Documentation alert: In addition to notations in the medical record, codes from Z55-Z65 (Persons with potential health hazards related to socioeconomic and psychosocial circumstances) “can be part of documenting circumstances in the patient’s life that support a moderate level of risk when those circumstances significantly limit diagnosis or treatment,” advises Jan Blanchard, CPC, CPEDC, CPMA, pediatric solutions consultant at Vermont-based PCC.

“Code assignment,” in such cases, “may be based on medical record documentation from clinicians involved in the care of the patient who are not the patient’s provider” as well as “patient self-reported documentation … as long as the patient self-reported information is signed-off by and incorporated into the health record by either a clinician or provider,” per ICD-10-CM Guidelines I.B.14 and I.C.21.c.17.

Hint 5: Understand That MDM Guidelines Provide More Insight

Last, when trying to calculate the level of MDM for a particular encounter, don’t make the mistake of simply using the MDM table to assign an office/outpatient E/M code. There are other tools at your disposal to help make this part of your job easier. “Many people go right to the MDM grid and miss all the important information in the guidelines, including the definitions, that precede it,” Jimenez noted.