Wiki Diagnosis and Management Options (MDM)

[Pathos]

Hello everyone,

One of our providers is seeing a new patient with several chronic conditions. He is managing three of these conditions (all problems new to him), however I am struggling with the Marshfield Clinic (MC) tool.

According to the MC tool, there is a Max=1 for New Problem without any additional workup done. Because the provider is managing several chronic conditions, it seems a bit unfair that he is getting penalized for the Max=1 and not able to get his 4 points in the Diagnosis and Management Options. I realize this might be where the MC tool is imperfect.

I can place one of the chronic conditions (fibromyalgia) in the New Problem without any additional workup, however I am puzzled as to where I can put the other 2 (chest pain, hypermobility). Since neither of the two problems are Established problems, I can't really put them there; however both might be too severe to be categorized as a "Self Limited/Minor" problem?

Any help/guidance would be greatly appreciated!

Thanks!

 

[thomas7331]

The Marshfield tool allows a max=1 for new problem without workup (which is a maximum of 1 problem, not a maximum of 1 point) because it assigns 3 points to a new problem, so it caps the points at the moderate level in this category if the provider is able to diagnose and manage the patient's problems in that visit and there is no uncertainty or need to refer the patient out for additional testing or specialist evaluation. Per CMS guidelines "decision making with respect to a diagnosed problem is easier than that for an identified but undiagnosed problem" even if there are multiple issues, and while no tool is perfect, as you've mentioned, I believe this piece of the Marshfield tool is intended to reflect this. The provider is not being 'penalized' - your provider will get the additional points in the other categories for reviewing records and data, and also for the additional history and exam that will be involved in managing the multiple problems, all of which will affect the level. Billing by time is an option too if the situation qualifies. A level 4 E&M is pretty standard for management of multiple stable and established chronic conditions in most payers' eyes, and I wouldn't recommend pushing this unless the documentation reflects factors that indicate this is a special case.

 

[Pathos]

The Marshfield tool allows a max=1 for new problem without workup (which is a maximum of 1 problem, not a maximum of 1 point) because it assigns 3 points to a new problem, so it caps the points at the moderate level in this category if the provider is able to diagnose and manage the patient's problems in that visit and there is no uncertainty or need to refer the patient out for additional testing or specialist evaluation. Per CMS guidelines "decision making with respect to a diagnosed problem is easier than that for an identified but undiagnosed problem" even if there are multiple issues, and while no tool is perfect, as you've mentioned, I believe this piece of the Marshfield tool is intended to reflect this. The provider is not being 'penalized' - your provider will get the additional points in the other categories for reviewing records and data, and also for the additional history and exam that will be involved in managing the multiple problems, all of which will affect the level. Billing by time is an option too if the situation qualifies. A level 4 E&M is pretty standard for management of multiple stable and established chronic conditions in most payers' eyes, and I wouldn't recommend pushing this unless the documentation reflects factors that indicate this is a special case.

Hello and thank you for your reply thomas7331,

To clarify the "Max=1", was referring to Max=1 problem as you mentioned above. I wanted to make sure the provider is not missing out on anything since he is managing several chronic conditions, and wanted to explore if there were other ways to give him credit were credit was due. Perhaps I am just overthinking this piece.

Thanks!