Podiatry Coding & Billing Alert

MDM:

Take a Second Look at the MDM Table

Published on Tue Sep 19, 2023

Does data factor into this office visit E/M claim?

Given the recent and extensive changes to the evaluation and management (E/M) codes, it’s always helpful to refresh your knowledge and understanding of E/M coding to benefit your practice. That’s why we’ve put together this scenario to see how well you’re grasping the nuances surrounding all the elements that go into determining the level of medical decision making (MDM), including the complex equations that comprise the amount and/or complexity of data to be reviewed and analyzed element.

Think you’re up for the challenge? Read on and see if you agree with our assessment.

Scenario: A 70-year-old new patient with dementia presents after falling off a three-step ladder. After an E/M service and some radiological exams of the foot, the podiatrist diagnoses the patient as having a closed fracture of the astragalus on the left foot. The podiatrist is able to gather more information related to the injury from the patient’s spouse, who accompanied them to the visit. The physician treats the swelling by applying a plaster-molded splint to immobilize and protect the fracture. Then, they refer the patient to an orthopedic clinic for follow-up treatment in two days.

Calculate the Data Correctly

As you consider which codes to choose for this encounter, it’s important to remember the MDM table and how the complexity of data to be reviewed and analyzed element applies to this visit.

“In the past, if you ordered one or five radiology tests, you only could claim one point for that. Now that they have added into the data section, they are finally making sure practitioners are getting credit for each unique source of data and testing,” said Betty A. Hovey, BSHAM, CCS-P, CDIP, CPC, COC, CPMA, CPCD, CPB, CPC-I, AAPC Approved instructor during her presentation, “Understanding the MDM Table,” at the La Crosse, Wisconsin, AAPC chapter meeting in August.

“The expansion of the data column is good in one way, but has added so much complexity in there, that you must be much more precise in your documentation in order to get credit for everything properly. I always say to the practitioners, ‘If you think it, ink it. Otherwise, you can’t get credit,’” said Hovey.

Remember: If the physician is separately reporting a CPT^®code that includes interpretation and/or report, this interpretation and/or report should not be counted in the MDM when selecting an office visit code.

Capture Independent Historian’s Input

Given the patient’s existing dementia diagnosis, the practitioner depended upon the patient’s spouse to provide a comprehensive account of the injury’s circumstances. Because of this, the spouse would be considered an independent historian. Independent historians are relied upon when the patient has a medical condition which renders them unable to communicate effectively, or they are considered unreliable due to a developmental delay or, in this case, a dementia diagnosis. When you do this, “you need to make sure the practitioner documents the reason for using the independent historian,” said Hovey.

Note: The independent history does not need to be taken in-person during the office visit, but it does need to be obtained directly from the historian providing the independent information. “The practitioner’s notes need to be very clear. For example, ‘Due to patient’s developmental status, history obtained from spouse’ would be an effective note,” said Hovey.

Coding the E/M

You may think you can make a case for the E/M MDM level in this situation to be moderate. After all, the podiatrist ordered and interpreted the X-rays and relied on the assessment of the independent historian (the patient’s spouse). This would satisfy the Category 1 requirement for the moderate level of data to be analyzed element of MDM.

However, this is only one of two MDM elements that must be met or exceeded. As the patient only has one acute, uncomplicated injury, the number and complexity of problems addressed at the encounter only rises to the low level. Similarly, the patient’s risk of morbidity from treatment — the splint and follow-ups with an orthopedic specialist — is low; the patient’s treatment does not qualify as minor surgery, and so cannot rise to the moderate level. With only the data element exceeding the low level, the office/outpatient E/M MDM level for this encounter only meets the low level.

This makes 99203 (Office or other outpatient visit for the evaluation and management of a new patient, which requires a medically appropriate history and/or examination and low level of medical decision making. When using time for code selection, 30-44 minutes of total time is spent on the date of the encounter) the most appropriate choice for the E/M level for this scenario if you decide to choose the level based on MDM alone. A higher level of E/M may be more appropriate should the total time the podiatrist spends with the patient exceed the 44-minute threshold for a 99203 encounter.

Radiology exams: Because the podiatrist ordered and interpreted an X-ray of the foot, and because this was not factored into the E/M MDM calculation, you can go ahead and bill 73620 (Radiologic examination, foot; 2 views)-LT (Left side) when you submit the claim for this encounter.