Primary Care Coding Alert

Boost Your Diagnostic Element With 3 Proven Strategies

Published on Mon Sep 15, 2003

Get inside your FP's head to code E/M services appropriately

Want an easy way to more accurately reflect the medical decision-making (MDM) level? Encourage your family physician (FP) to report all pertinent diagnoses.

1. Include All Relevant ICD-9 Codes

Failing to document all pertinent diagnoses is the number-one mistake that FPs make when determining the MDM type - straightforward, low complexity, moderate complexity, and high complexity - says Sandra Soerries, CPC, CPC-H, a coding and compliance consultant at RSM McGladrey in Kansas City, Mo. At the minimum, an office visit (99201-99215, Office or other outpatient visit for the evaluation and management of a new or established patient ...) will include a diagnosis and treatment plan, she says.

If the FP considers additional diagnoses or treatment options, this will raise the diagnostic uncertainty element. Here's how to know if an office visit qualifies for a higher level: Urge your FP to write a few words that indicate she thought of a range of diagnoses and selected one based on the available information.

Remember: To qualify for a particular MDM type, the visit must meet or exceed two of the following three elements:

number of diagnoses or management options

amount and/or complexity of data to be reviewed

risk of complications and/or morbidity or mortality.

2. Watch for Underlying Conditions

Encourage your physicians to list more than the primary diagnosis, says Kim Spinosi, CPC, billing specialist at Physician Health Alliance Inc. in Scranton, Pa. When the FP treats and documents relevant chronic conditions, this helps raise the MDM level, which in turn may boost the level of E/M service, she says.

For instance, a controlled-diabetic male patient presents with a runny nose and sniffles without any "serious" illness. Listing only one diagnosis, such as 460 (Acute nasopharyngitis [common cold]), will make the visit qualify for the lowest diagnostic element: minimal. But if the FP also considers the effect the patient's diabetes (250.00, Diabetes mellitus without mention of complication; type II [non-insulin dependent type] [NIDDM type] [adult-onset type] or unspecified type, not stated as uncontrolled) has on management options and treats the condition, she should report 250.00 for addressing the underlying disease. Coding the chronic condition will boost the diagnosis and management options element from minimal to limited, Spinosi says.

3. Tally Diagnoses and Treatment Options

Even if your FP chooses the diagnosis and management options element, she must explain in enough detail why she selected a particular level. His MDM roadmap should allow you or an outside auditor to check a sample of his work.

To determine or audit physician-assigned MDM levels, Soerries uses a chart that awards points to the number of diagnoses or treatment options in the following manner - See table at top of page.

What the score means - See second table.

Test yourself: Try scoring the following scenario using the auditing tools.

MDM scenario: A 55-year-old female established patient returns today for follow-up of menopausal symptoms. Estrogen replacement therapy is curtailing her hot flashes and mood swings, but she complains of monthly bleeding. The FP adjusts the dosage of estrogen pills and recommends considering changing brands if the problem does not resolve.

The patient's menopausal disorder (627.2, Menopausal and postmenopausal disorders; symptomatic menopausal or female climacteric states) constitutes an established, previously diagnosed problem that is responding to management, so it rates one point. As a previously undiagnosed problem, the bleeding (627.1, Postmenopausal bleeding) rates three points. Therefore, with four points, the scenario qualifies as extensive.