Wiki MDM risk

[ivygirl18@hotmail.com]

Hello,

I did an audit and the provider is coming back and saying the patient had a stroke and difficulty swallowing and that is why they are being admitted to the NH. The provider is saying this could be high risk? However, in the CC/HPI area the patient states they are improving and in the assessment the patient's status is fair. How would you determine a diagnosis to be high risk? Should the provider document something?

How would you determine what is high risk??

 

[thomas7331]

The level of risk is probably the most subjective of all the elements used in auditing an E&M level so this is not an easy answer. I frequently refer coders to the statement about risk in the CMS 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. The assessment of risk of selecting diagnostic procedures and management options is based on the risk during and immediately following any procedures or treatment." I think this is useful because it shows that risk is not just tied to a particular diagnosis, but rather is a measure of the provider's assessment of the patient's condition at that encounter, and so this is information that should be reflected in documentation in addition to the diagnosis.

You've said the provider documented that the patient's status is 'fair', so I think your question as to why this is a high risk patient is legitimate. But since an accurate assessment of risk can involve clinical measures that a coder is not trained to interpret, many coders/auditors I've encountered will defer to the provider's judgment for the risk level. And in cases where the auditor assesses one level of risk and the provider another, auditors will often use it as a starting point for a discussion rather than citing it as an error, and I think that's the best approach. It's an opportunity to review the guidelines with the provider and have them give you input as to why, in their clinic judgment, they feel the patient is high risk, and for you to explain to them why the documentation, to an auditor's eye, does not support that.

I'd also make a reminder that risk is only one element of MDM and that for high level MDM, the documentation also needs to reflect either extensive number of diagnoses and/or extensive review of data. In your example, you've said the patient is improving, so unless the provider is managing more than 3 problems or reviewing extensive data, then the designation of high risk would be something of a moot point as it would still not result in high level MDM.

 

[twizzle]

The level of risk is probably the most subjective of all the elements used in auditing an E&M level so this is not an easy answer. I frequently refer coders to the statement about risk in the CMS 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. The assessment of risk of selecting diagnostic procedures and management options is based on the risk during and immediately following any procedures or treatment." I think this is useful because it shows that risk is not just tied to a particular diagnosis, but rather is a measure of the provider's assessment of the patient's condition at that encounter, and so this is information that should be reflected in documentation in addition to the diagnosis.

You've said the provider documented that the patient's status is 'fair', so I think your question as to why this is a high risk patient is legitimate. But since an accurate assessment of risk can involve clinical measures that a coder is not trained to interpret, many coders/auditors I've encountered will defer to the provider's judgment for the risk level. And in cases where the auditor assesses one level of risk and the provider another, auditors will often use it as a starting point for a discussion rather than citing it as an error, and I think that's the best approach. It's an opportunity to review the guidelines with the provider and have them give you input as to why, in their clinic judgment, they feel the patient is high risk, and for you to explain to them why the documentation, to an auditor's eye, does not support that.

I'd also make a reminder that risk is only one element of MDM and that for high level MDM, the documentation also needs to reflect either extensive number of diagnoses and/or extensive review of data. In your example, you've said the patient is improving, so unless the provider is managing more than 3 problems or reviewing extensive data, then the designation of high risk would be something of a moot point as it would still not result in high level MDM.

Thomas, you are one of the few people on this forum whose responses are accurate, legit, and make complete sense. I have to agree with your assessment and responses to the poster's question.

I do E&M auditing and provider education all the time, and agree that the risk is the most subjective element in all E&M encounters. My client has, to some degree, set some of their own rules regarding documentation, and under the area of risk comes Rx drug management. They have elected to base the level of risk for Rx drug management for antibiotics on what condition is being treated; this can and does put an auditor in the position of making clinical judgements which can be tough. Some are easy decisions, others not so easy. I have a clinical background but still struggle with this concept.

So a relatively straightforward problem requiring antibiotics would be designated as low risk, a more serious problem as moderate risk. Obviously for very serious, life-threatening infections, we are in the high risk area but that is easier to evaluate in my opinion.

I don't have anything further to add to your response other than what I said above; my point is that we inevitably do have to make clinical judgements every day when we audit E&M, whether we like it or not.

 

[ivygirl18@hotmail.com]

Thank you both for your responses.

Thomas--How you explained it was the way I was thinking, but I was getting caught up on the provider stating the patient's condition was fair, however this could change from the current visit till the next. If the provider would not have documented fair I would have done high risk per the problems.

The provider did have over 3 diagnoses they were addressing. All of the other elements supported the level.


Thank you,

Abby