Pitfall: Don't miss the "if this, then that" notes when determining level of risk. When it comes to choosing the overall level of service for an evaluation and management encounter, such as an office visit, most coders will tell you that determining the medical decision making (MDM) complexity is the most complicated and difficult piece of the puzzle. If MDM is the bane of your coding existence, you aren't alone. To determine the level of MDM, you should assign points to each of the three MDM components that your urologist performs. The number of points in each category determines the final MDM level. There are three elements that contribute to the complexity of your urologist's medical decision making. "The elements are diagnoses/management options, complexity of data reviewed/ordered, and the table of risk," says Suzan Berman, CPC, CEMC, CEDC, Senior Director of Physician Services at Healthcare Revenue Assurance Associates based out of Plantation, Florida. You must have two out of the three MDM components score at a particular level in order to assign that level of MDM. For example, if the number of diagnoses is low, but the amount and complexity of data and level of risk are both moderate, your MDM score is moderate. An alternative method to determine the correct level of MDM is to eliminate the highest and lowest scores, and the remaining score is the level for the particular MDM in question. Follow this three step process to determine each component level. 1. Understand Each Level of Diagnosis Start your MDM level assessment by tackling the first category: number of diagnoses. For this category, ask, "What is wrong with the patient?" and "What is the total number of medical diagnoses that the patient has that the urologist addressed during the encounter?" For each diagnosis, you will assign a point and score the diagnosis level as follows, says Chandra L Hines, practice supervisor of Wake Specialty Physicians in Raleigh, NC: Use the worksheet on page 70 to determine the point value to assign. "The point system has been adopted by most insurance carriers; however, it is officially the "Marshfield system," Berman explains. "Trailblazers, for example use a different point structure." Example: Score: 2. Classify Your Data Complexity The second component to consider when deciding on your urologist's MDM complexity is the amount and complexity of the encounter's data. For this piece of the MDM puzzle, you need to determine if your urologist's work included the following classes of data: You will score the complexity of data in the same manner as the diagnoses: minimal (0-1), low/limited (2), moderate (3), and high (4+). Review the worksheet on page 70 for details. Remember: Score: 3. Weigh the Risk The final of the three MDM categories, level of risk, can be the most difficult part to determine. "This is the most confusing component of the MDM section," Berman says. "We really need to be in tune with our physicians and the diseases processes for which we code. This helps. It also helps with the physician is thorough and complete in the documentation so that we can determine patient specific risks, therapies ordered, etc." Level of risk involves three subcategories: presenting problem, diagnostic procedures ordered, and management options. Comorbidities, the need for diagnostic testing, the plan of care, and so on, may complicate the medical decision making, Hines explains. The highest score from only one of the three categories (not from each category) determines the patient's risk level, minimal, low, moderate, or high. Learn more: For the earlier example, when you look at the table of risk, the patient has one new acute uncomplicated illness (renal colic) and two stable chronic illnesses (diabetes and hypertension), which combine for a moderate risk level for the presenting problems column. The lab order and the CT scan order lead to low risk for the diagnostic procedures ordered. Since the urologist did not order any treatment other than rest and over the counter medication for this encounter, the level of management option risk is low. The moderate risk presenting problems result in an overall moderate risk level. Future planning pointer: "Explaining that they're trying the more conservative treatment, but that the patient may require a more aggressive approach, can boost the level of MDM," she adds. "Documenting the extra step shows that the physician considered more management options (one element of MDM)." Don't get emotional: Final MDM: