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Pulmonology Coding Alert

Medical Decision-Making Helps Procure $35 Worth of Your Time

Published on Thu May 01, 2003

If you've been downcoding to a level-four office visit or lower just to play it safe, you may be missing out on some well-deserved reimbursement.

Facing CMS scrutiny of high-level office visit coding and complicated coding guidelines, many practices shy away from reporting 99215 for physician services to escape possible audits. However, you can avoid this problem by learning some clear-cut rules regarding criteria for high-level E/M visits.

If your physician's services adequately qualify for a higher-level E/M code, it could mean the difference of about $30 or $35 as you move up the scale from a 99213 to a 99215.

E/M Level Takes Two Out of Three

You use three key components to determine the level of E/M service to report. These include the history taken at the time of the visit, the extent of physical examination, and medical decision-making (MDM). For office or other outpatient visits for established patients, you must meet the criteria for two of the three key components to bill for a specific level of care.

Most coders find the MDM piece of the puzzle the hardest to fit into place. Determining the difference between straightforward (S), low (L), moderate (M) and high (H) MDM can be an arduous task. You determine the level of MDM by looking at two of its three categories:
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 co-morbidities associated with the patient's presenting problem(s), diagnostic procedure(s) and/or the possible management options.

Unlock Reimbursement With Key Element of 'Risk'

Determining the level of risk can be the hardest of the three components because it requires more than just counting diagnosis options or lab tests ordered. According to Catherine Brink, CMM, CPC, president of Healthcare Resource Management of Spring Lake, N.J., this category includes risks associated with the presenting problems, the diagnostic procedures, and the possible management options. The highest level of risk in any of these areas determines the overall risk. Take the four levels of risk as examples:

  • Minimal One minor problem. Diagnostic procedures include laboratory tests requiring venipuncture, x-rays, urinalysis, or ultrasounds. Management options include rest and simple bandages.

  • Low Two or more minor problems, one stable chronic illness or an acute uncomplicated illness. Diagnostic procedures include superficial needle biopsies, laboratory tests requiring arterial puncture, non-cardiovascular imaging studies such as barium enema, and physiologic tests not under stress. Management options include over-the-counter drugs, minor surgery with no risk factors, therapy, and IV fluids without additives.

  • Moderate One or more chronic illnesses with mild exacerbation, two or more stable chronic illnesses, an undiagnosed problem, acute illness with systematic symptoms or an acute complicated injury. Diagnostic procedures include physiologic tests under stress, diagnostic endoscopies with no risk factors, deep needle or incisional biopsy, cardiovascular imaging studies with contrast and no risk factors, and obtaining fluid from the body. Management options include minor surgery with identified risk factors, elective major surgery with no risk factors, prescription drug management, therapeutic nuclear medicine, and IV fluid with additives.

  • High One or more chronic illnesses with severe exacerbation or progression, acute or chronic illnesses or injuries that may pose a threat to life or bodily function or an abrupt change in neurologic status. Diagnostic procedures include imaging studies with contrast and identified risk factors, cardiac electrophysiological tests, and diagnostic endoscopies with risk factors. Management options include elective major surgery with risk factors, emergency major surgery, parenteral controlled substances, drug therapy requiring intensive monitoring for toxicity, and the decision not to resuscitate or to deescalate care because of poor prognosis.

    Add Diagnostic Options to the Mix

    Although determining the level of risk may be the most difficult for you, the number of diagnoses and treatment options should not be overlooked. According to CMS guidelines, the number of possible diagnoses and management options that must be considered is based on the number and types of problems addressed during the encounter, the complexity of establishing a diagnosis, and the management decisions made by the physician.

    You must document an assessment, clinical impression, or diagnosis for each encounter, along with the initiation, maintenance or change in treatment and any consultations or referrals initiated. For a presenting problem with an established diagnosis, document whether the problem is (1) improved, well controlled, resolving or resolved or (2) inadequately controlled, worsening or failing to change as expected. You can use the number and type of diagnostic tests employed as an indicator of the number of possible diagnoses. You may consider each of the problems that is documented in the progress note by the physician.

    Document Complexity of Data

    It is important for the physician to document what he reviewed, tests performed, tests reviewed, and past medical records reviewed, Brink says. If it is not documented, you cannot count it toward the complexity-of-data category of MDM. According to CMS, the amount and complexity of data to be reviewed is based on the types of diagnostic testing ordered and reviewed. The decision to obtain and review old medical records and the discussion of unexpected test results with the physician who performed or interpreted the tests is one indicator of the complexity of data to be reviewed.

    Clear Up the Confusion With Four Case Studies

    Considering the myriad information you have to assimilate to determine the level of MDM, you should take a look at the following examples provided by  Charlie Strange, MD, FCCP, director of the medical intensive care unit at the Medical University of South Carolina in Charleston:

  • Scenario #1: Straightforward MDM. A long-term COPD patient returns to the office for medication refills. The physician inquires about medication frequency and efficacy and performs an abbreviated physical exam to look for wheezing. He checks vital signs including oximetry, determines if objective testing with spirometry will influence the treatment course, and renews medications. Rationale: 1 Dx/Tx options pt, 1 data point, moderate risk.

  • Scenario #2: Low-Complexity MDM. A patient comes in showing signs of a cough, low-grade temperature, and sinus congestion. The physician determines that it is viral and suggests over-the-counter medications to alleviate the symptoms. Rationale: 4 Dx/Tx option pts, 0 data pts, low risk for OTC drugs or acute, uncomplicated illness.

  • Scenario #3: Moderate MDM. A 40-year-old male who has been a smoker presents in the office with episodic wheezing. The pulmonologist elicits a medical history of exercise-induced worsening and cat sensitivity. A past medical history reviews possible exacerbating drugs. A review of systems determines if other allergic symptoms are present (e.g., allergic rhinitis or conjunctivitis). He obtains social and family history. The physical exam focuses on HEENT, lung and skin exams. The medical decision-making focuses on how and whether to screen for allergens and advancing a treatment plan. He demonstrates new medication devices. Rationale: 4 Dx/Tx option pts, 1 data point if allergy testing is ordered, moderate risk for undiagnosed new problem or Rx management.

  • Scenario #4: High MDM. Apatient returns for follow-up after a bronchoscopy for a lung mass performed two days ago. The physician had spent one hour discussing the probability the mass was lung cancer at the last visit. He reviews the pathology showing cancer, discusses the next steps in a staging workup, and makes visits to the consulting oncologist and/or radiation therapist. The pulmonologist spends at least half the visit assuring that the patient has sufficient emotional support systems in place. Rationale: 4 Dx/Tx option pts, 1 data pt, high risk for an acute illness that poses a threat to life or bodily function.

  • Scenario #5: Nurse Visit. A 25-year-old established patient presents in the office to see the nurse, who reviews the side effects of a new medication that was started. The patient does not see the doctor.

    Putting all of these components together to come up with a level of medical decision-making can be quite a task, so use the chart on page 39 to clear up your coding difficulties.

    Note: The chart uses the method established by the Medical Group Management Association (MGMA) in its E/M Documentation Auditor's Worksheet, which helps quantify the components of MDM. Copies of the complete worksheet can be ordered from MGMA by calling (887) ASK-MGMA. More examples of medical decision-making can be found in Appendix C of the CPT Manual. CMS' 1997 guidelines for the documentation of evaluation and management services are available at http://cms.hhs.gov/medlearn/emdoc.asp.

     

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