Below are the guidelines for NHIC (Northern New England). Although NHIC says that "Physician MDM is critical to determine the overall level of care provided during a patient encounter", I don't necessarily interpret this to mean that MDM must always be one of the two key components, in fact, I don't see that specific language anywhere in the documentation guidelines. I believe that what NHIC is saying is that MDM must always be clearly documented...the presenting problem, status, treatment, and physician's overall thought process, and that by understanding the nature of the presenting problem and the elements of MDM, you can ascertain the necessity of the other key components as relatated to that problem. That concept is what makes MDM critical, and a good place to start, but it may not be the overarching criteria....medical necessity is. I think a lot of coders get caught up in counting all of the bullets, and although that's a part of it, it doesn't always result in the appropriate level of service if the bullets aren't medically necessary. E&M auditing isn't an exact science, but it's interesting once you understand the concept.
Medical Decision Making
[FONT=Book Antiqua,Book Antiqua][FONT=Book Antiqua,Book Antiqua]Medical decision making (MDM) is considered the thought process of the physician. MDM refers to the complexity of establishing a diagnosis and selecting a management and treatment option as measured by the following: [/FONT]
[FONT=Book Antiqua,Book Antiqua]The number of possible [/FONT][/FONT][FONT=Book Antiqua,Book Antiqua][FONT=Book Antiqua,Book Antiqua]diagnoses [/FONT][/FONT][FONT=Book Antiqua,Book Antiqua][FONT=Book Antiqua,Book Antiqua]and/or the number of management options that must be considered. [/FONT]
[FONT=Book Antiqua,Book Antiqua]The amount and/or complexity of [/FONT][/FONT][FONT=Book Antiqua,Book Antiqua][FONT=Book Antiqua,Book Antiqua]data - [/FONT][/FONT][FONT=Book Antiqua,Book Antiqua][FONT=Book Antiqua,Book Antiqua]medical records, diagnostic tests, and/or other information that must be obtained, reviewed and analyzed. [/FONT]
[FONT=Book Antiqua,Book Antiqua]The [/FONT][/FONT][FONT=Book Antiqua,Book Antiqua][FONT=Book Antiqua,Book Antiqua]risk [/FONT][/FONT][FONT=Book Antiqua,Book Antiqua][FONT=Book Antiqua,Book Antiqua]of significant complications, morbidity and/or mortality, as well as co-morbidities, associated with that patient's presenting problem(s), the diagnostic procedure(s) and/or the possible management options. [/FONT]
[FONT=Book Antiqua,Book Antiqua]The complexity of MDM should be documented accordingly and not inferred or implied. For each encounter, an assessment, clinical impression, or diagnosis should be documented. Physician MDM is critical to determine the overall level of care provided during a patient encounter. MDM may vary on a visit-to-visit basis depending on the patient's condition and what the physician performed that day. The fact that the patient has an underlying disease or co-morbidity is significant only if their presence significantly increases the complexity of the MDM. Only conditions that impact the encounter are determining factors that affect the level of E/M service. The current status of the patient's diagnosis is also a determining factor i.e. stable, improved, worsening etc. Diagnoses count in the MDM leveling only if they impact the presenting problem. Generally, decision making with respect to a diagnosed problem is less complex than an identified but undiagnosed problem. [/FONT]
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