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Practice Management Alert

E/M:

See Through the Haze of MDM Confusion

Published on Wed Oct 20, 2021

Hint: Listing all possible diagnoses can bolster evidence of MDM.

2021 brought many evaluation and management (E/M) changes, including outpatient E/M codes (99202-99215). Providers should be conducting patient history and examinations, as the patient’s care warrants, but those elements of the encounter are no longer deciding components for office or outpatient E/M services.

Knowing how to navigate the rules for time spent and medical decision making (MDM) is now crucial to coding E/M services for office/outpatient encounters. Bolster your confidence in your E/M MDM coding with this advice from Barbara J. Cobuzzi, MBA, CPC, COC, CPC-P, CPC-I, CENTC, CPCO, CMCS, of CRN Healthcare in Tinton Falls, New Jersey.

Tip 1: Know Which Elements Can Dictate MDM Level

As most coders know, the MDM table includes three elements that can help you select the MDM level:

  • Number and complexity of problems addressed
  • Amount and/or complexity of data to be reviewed and analyzed
  • Risk of complications and/or morbidity or mortality of patient management

If you’re poring over charts and reports to try and pinpoint an MDM level because you want to meet all three criteria, keep in mind that you must only meet two of the three to justify a particular MDM level, Cobuzzi said.

“This means that if one area is weak, we are able to drop it — and counting the data elements can be a challenge. There are a lot of variables that you can have arguments with payers about in terms of collection of data, and it’s my recommendation that, when possible, you concentrate on the number and complexity of problems being addressed during your encounter rather than the amount of complexity of data being reviewed. And then also focus on the risk of complications and morbidity or mortality of patient management.”

Tip 2: Define ‘Problem’

When you’re evaluating the number and complexity of problems addressed, keep in mind that if you see a patient with a high number of differential diagnoses, you should be listing them all to justify MDM, even though you’re ultimately going to assign just one diagnosis to the patient’s claim for the day, Cobuzzi said.

The reason is because you need to count all of the problems that the physician addresses, she said. “Let’s talk about what a problem is,” she noted. “A problem is a disease, a condition, an illness, an injury, a symptom, a sign, a finding from a lab, a complaint, or other matters that are being addressed during the visit, with or without a diagnosis being established at the time of the visit.”

Dizziness is an example where many differential diagnoses are evaluated (and in the past, physicians felt they did not get credit for the extra work involved). Now, a provider can count all of the possible diagnoses considered for a dizzy patient, which increases the complexity of problems addressed for the MDM.

Additionally, she said, a patient can give you a sign or symptom, but you may not establish a diagnosis for that problem during the visit. However, evaluating it still adds complexity to that visit.

Tip 3: Make Decisions Via Records

The point of documenting all the problems you addressed during a visit is to make sure a payer would be able to visualize the thought process you used while analyzing a patient’s problems (and managing them), Cobuzzi said.

“You want to think and ink,” she said. “Take everything you’re thinking and record it as part of the medical decision making.”

Tip 4: Document Treatment Goals

When you’re reviewing the number and complexity of problems addressed, you’ll note that you have the option of evaluating what the MDM table refers to as “stable, chronic illnesses.” For most practices, “chronic” mean that the illness will last at least one year or until the death of the patient. But for the “stable” part of the definition, it may be a little bit more challenging to evaluate.

“Stable means the patient is at their specific treatment goals,” Cobuzzi said. For instance, let’s say the patient has frequent diarrhea attacks and you set a goal that they will only get one bout of diarrhea or fewer in a month. If they only get one bout that month, then that’s considered a stable, chronic illness. But if you had set your goal indicating that they would have no diarrhea and they end up having it, then you cannot consider them stable.

To ensure that you can determine when a patient is considered stable, you should add a line to your templates so when a patient has a chronic illness, you have a place to enter a treatment goal. “The physician should be wanting to add examples for the patient, and there can be interim general treatment goals,” Cobuzzi said. For instance, in the beginning, you might want the patient to get down to three bouts of diarrhea in a month, and then you want them to get down to one bout in a month, and then you want them to get down to no diarrhea per month — this way, you don’t want to make it so that your treatment goals are impossible, that they’ll never get out of into a stable illness.

Note that in CPT® guidelines, “A patient who is not at his or her treatment goal is not stable, even if the condition has not changed and there is no short-term threat to life or function.” This is a particularly important concept because an unstable condition qualifies as moderate rather than low complexity, so might qualify the encounter for level 4 rather than level 3.

Resource: To review the AMA’s MDM chart, visit https://www.ama-assn.org/system/files/2019-06/cpt-revised-mdm-grid.pdf.

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