Wiki 2021 E/M Guidelines MDM Severity Sleep Apnea

[dreamsleepmed]

I am working with my sleep physician on coming up with a plan for next week. One of the issues that was brought up is the new 2021 guidelines state that high complexity can be obtained if you have an "acute or chronic illness or injury that poses a threat to life or bodily function". My sleep physician is wondering if sleep apnea would meet this criteria as it significantly raises the risk of MI, Stroke, and sudden death if left untreated. I feel that he may have a case for patients with more moderate to severe disease but am not sure that mild sleep apnea would qualify. Does anyone have a sense for if these scenarios would meet this criteria? Thanks!

 

[Lyta2000]

I would not put sleep apnea as anything other than chronic illness/ stable. If we looked at it the way the doctor is then a lot is diseases could be classified that way. A patient with diabetes has a chronic illness that could pose a threat to life or bodily function” if you look at it like your doctor. I don’t think it makes sense if the threat is not immediate. Just my thought.

 

[thomas7331]

I agree, virtually any illness can potentially be a threat to life or bodily function if left untreated - that does not mean it is the case at every given encounter for that disease.

The intent of the guidelines has always been that the documentation should reflect the severity of illness of the patient under evaluation at that encounter - not that one disease or another is always classified at a given level of severity. As was stated back in the original 1995 guidelines: "Because the determination of risk is complex and not readily quantifiable, the table includes common clinical examples rather than absolute measures of risk. The assessment of risk of the presenting problem(s) is based on the risk related to the disease process anticipated between the present encounter and the next one."

I would advise a provider that if he or she feels that an encounter warrants coding as high complexity because a patient's is at high risk, then the assessment and treatment plan documented for the encounter needs to reflect this. A coder cannot make the assumption that any particular disease is any particular level of risk without documentation to support it.

 

[lcolborn]

I told our providers, if they think the patient is in imminent danger between now and subsequent visit , then aim for that level 5. However, to meet a level 5 you have to meet two from the three columns for elements in the MDM Grid.