Practice Management Alert

Question: One of our newer coders filed an erroneous claim recently in which she assigned a level-three E/M service when our nurse taught a hepatitis patient how to self-inject Interferon. The coder said she didn't understand how to assign the level of medical decision-making (MDM). What are some things we can tell her to remember when determining MDM?

Missouri Subscriber

Answer: The coder should have reported 99211 (Office or other outpatient visit for the evaluation and management of an established patient, that may not require the presence of a physician) for the Interferon education visit. 99211 is the only E/M code you can report for a nurse's services.

When you report E/M services, you must consider the level of MDM whether you use the new patient code set (99201-99205, Office or other outpatient visit for the evaluation and management of a new patient ...) or the established patient set (99211-99215, Office or other outpatient visit for the evaluation and management of an established patient ...) -- or any E/M service, for that matter (consults, hospital visits, etc.).

The MDM maze can be hard to navigate when determining E/M level. For example, E/M guidelines dictate that 99212 requires straightforward MDM, whereas the higher-level code 99214 requires MDM of moderate complexity. When selecting between straightforward, low, moderate and high MDM, look at these aspects of the visit:

1. Number of possible diagnoses and/or management options
2. Amount and/or complexity of medical records, diagnostic tests and/or other information that is obtained, reviewed and analyzed
3. Risk of significant complications, morbidity and/or mortality including comorbidities associated with the patient's presenting problem(s), diagnostic procedure(s) and/or the possible management options.

-- The answers to the Reader Questions were provided and/or reviewed by Brenda W. Messick, CPC, chief administrator at Georgia Reproductive Specialists in Atlanta; and Catherine A. Brink, CMM, CPC, president of Healthcare Resource Management Inc., in Spring Lake, N.J.