Wiki E/M Coding definitions

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HeatherPaigeOsborn

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Will someone please clarify a few questions regarding some of the key elements for History and MDM:

1. For Duration under HPI I was instructed that I need an exact date of onset. I now have an auditor saying "Sept of last year" and "Pathology on 12/15/16" are acceptable to use under duration. Please confirm.

2. For Severity under HPI I was instructed to use anything with a scale of pain or stage / grade of disease, the auditor is using "Metastatic" and "increasing pain". Which is correct?

3. What details are needed to include all 4 extremities under Physical exam?

4. In order to obtain points for "Independent review" under MDM, reviewed/ordered data are things like "We looked at her MRI scans and you can clearly see the recurrence" or "We looked at the films together and I mapped out the changes for him" considered acceptable proof of Independent review?

5. For MDM, specifically for a follow up visit, how does one determine the complexity if they are not returning for their "Chief complaint"? Should it be just for today's visit, or include the patient's previous disease?
 
HeatherPaigeOsborn said:
Will someone please clarify a few questions regarding some of the key elements for History and MDM:

1. For Duration under HPI I was instructed that I need an exact date of onset. I now have an auditor saying "Sept of last year" and "Pathology on 12/15/16" are acceptable to use under duration. Please confirm.

2. For Severity under HPI I was instructed to use anything with a scale of pain or stage / grade of disease, the auditor is using "Metastatic" and "increasing pain". Which is correct?

3. What details are needed to include all 4 extremities under Physical exam?

4. In order to obtain points for "Independent review" under MDM, reviewed/ordered data are things like "We looked at her MRI scans and you can clearly see the recurrence" or "We looked at the films together and I mapped out the changes for him" considered acceptable proof of Independent review?

5. For MDM, specifically for a follow up visit, how does one determine the complexity if they are not returning for their "Chief complaint"? Should it be just for today's visit, or include the patient's previous disease?
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I hope this helps:

1. Yes, this is correct. As long as they notate how long, it doesn't matter the phrasing, this is counted as duration.
2. Increasing Pain would be correct. Also they can use the Pain Scale (1-10)
3. No edema (legs), No clubbing (hands). Full ROM on all extremities. etc....
4. Yes, as long as they state they PERSONALLY reviewed the image, specimen, or tracing itself (not simply review of the report)
5.you ONLY look at today's presenting issue(s). Anything in the past, including histories noted, are NOT included in the MDM. It is only what is addressed on that visit ONLY.

I train providers on how to properly document for E/M coding. It used to be my weakest area of coding and now it's my strongest. I audit all the time and I use Novitas Interactive E/M Tool. You should try it! Google it and you will find it extremely helpful and give you great info on what is needed.
 
E&M Tool

Thank you for the E&M interactive tool! Saved it to my favorites!
 
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