Medical
Decision Making Is one of the three key components in deciding the level of
E&M. As per CMS 2015
updates, we should consider MDM as one of the components in deciding the level of
E&M.
MDM is considered based on below 3 criteria,
1. The
number of diagnosis,
2. Review
of data,
3. The
risk of significant complication.
A. Number
of Diagnoses and/or Management Options:
The number of
possible diagnoses and/or the number of management options to consider is based
on:
- The number and
types of problems addressed during the encounter,
- The complexity
of establishing a diagnosis; and
- The management
decisions made by the physician.
1.
Generally, decision making for a diagnosed problem is easier than
decision making for an identified / undiagnosed problem.
2.
The number and type of diagnosed tests performed would be an
indicator of the number of possible diagnoses.
3.
Problems that are improving or resolving are less complex than
those problems that are worsening or failing to change as expected.
4.
Another indicator of the complexity of diagnostic or management
problems is the need to seek advice from other health care professionals.
It’s the
responsibility of the physician to document all the necessary information in
the medical record to arrive more appropriate E&M.
1. All the Diagnosis for that encounter
must be documented, with additional information like whether it's an established
or new condition to the physician,
An established diagnosis, whether the problem is:
- Improved, well-controlled, resolving, or resolved; or
- Inadequately controlled, worsening, or failing to change as expected.
A new diagnosis, whether
- Additional workup is needed or
- Additional workup is not required
B. Amount and/or Complexity of Data to be Reviewed.
Is based
on the types of diagnostic testing ordered or reviewed.
A decision to obtain and review old medical records and/or obtain a history from sources other than the patient,
Discussion of test results with the physician who performed
or interpreted the test,
The physician ordered a test and personally reviews the image, tracing,
or specimen to supplement information from the physician who prepared the
test report or interpretation.
The physician should document the following in the visit notes, if applicable.
- If a diagnostic test is ordered, planned, scheduled, or performed at the time of the E/M encounter.
- The review of
laboratory, radiology, and/or other diagnostic tests. A simple
notation such as “WBC elevated” or “Chest x-ray unremarkable” is
acceptable. Alternatively, document the review by initialing and dating
the report that contains the test results.
- A decision to obtain
old records or obtain additional history from the family, caretaker, or other source to supplement information obtained from the patient.
- Relevant findings from the review of old records and/or the receipt of additional history from the family, caretaker, or other source to supplement the information
obtained from the patient.
- Discussion about
results of laboratory, radiology, or other diagnostic tests with
the physician who performed or interpreted the study; and
- The direct
visualization and independent interpretation of an image, tracing,
or specimen previously or subsequently interpreted by another
physician.
C. The risk of significant complications, morbidity, and/or mortality
Is based on the risks associated with the following categories,
- Presenting problem(s);
- Diagnostic procedure(s); and
- Possible management options.
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
encounter.
The assessment
of risk of selecting diagnostic procedures and management options is based on
the risk during and immediately following any procedures or treatment.
The highest
level of risk in any one category determines the overall risk.
The level of
risk of significant complications, morbidity, and/or mortality can be:
- Minimal;
- Low;
- Moderate; or
- High.
Below are some important points to keep in mind when documenting level of risk,
Co-morbidities/underlying diseases or other factors that increase the complexity of medical decision making by increasing the risk of
complications, morbidity, and/or mortality;
The type of procedure, if a surgical or invasive diagnostic procedure is
ordered, planned, or scheduled at the time of the E/M encounter;
The specific procedure, if a surgical or invasive diagnostic procedure is
performed at the time of the E/M encounter; and
The referral for or decision to perform a surgical or invasive diagnostic
procedure on an urgent basis. This point may be implied.
Question # 1.
The patient sees Doctor A in 2011 for left knee pain. The patient comes back
and sees Doctor B (a member of the same group with the same speciality) for
left knee pain in 2013. Is this a new problem to Doctor B?
Ans #1. For
purposes of the medical decision making for the E/M service, the left knee pain
is a new problem to both physicians. In both instances, the physician has not
addressed the problem previously. The second physician would submit an
appropriate level of established patient service since a physician in the same
group with the same speciality provided a face-to-face service within the
previous three years. While the problem is new to the second physician, the
patient is not.
Question # 2.
Define a self-limited or minor problem in the medical decision making grid
under the minimal level of risk. At times, it is difficult to determine whether
a problem is self-limited or minor or whether it is a new problem with no
additional workup planned.
Answer # 2. The
1995 and 1997 DGs indicate the determination of risk is complex and not readily
quantifiable and includes some examples in each of the categories. The DGs do
not address a new problem with no additional workup planned. Therefore, you can
use the examples provided in the DGs to determine the level of the presenting
problem.
Question
# 3. My physician is reviewing previous radiology reports, but not
providing an interpretation and report. Can we consider this as part of the MDM
portion of the E/M encounter?
Answer
# 3. Yes, this is part of the amount and complexity of data reviewed. Your
physician cannot submit a claim for the professional component of the radiology
procedure since he/she is not providing the interpretation and report. However,
your physician can document his/her review of the data. He/she would also
document how the data affects the patient's possible treatment.
Question
# 4. Can we use a referral or a decision for surgery in documenting the
amount and complexity of data reviewed?
Answer
# 4. A referral or a decision for surgery is part of the "risk of
significant complications, morbidity, and/or mortality" a portion of the
MDM.
Question
# 5. The patient has Parkinson's and the doctor addresses the impaired
gait, reduced appetite and language problems. In MDM, are these considered
separate "number of diagnosis or management options" or are they
simply considered part of the Parkinson's diagnosis?
Answer
# 5. These items would be part of the Parkinson's diagnosis and you would
not use these separately in choosing your level of MDM.
Question
# 6. My question centres on the number of diagnosis or management options
in the MDM of the E/M service. When coding an Emergency department encounter,
would all presenting problems fall under the "new problem" category
(either with or without additional workup)? When I place conditions such as
cold, otitis media, insect bite, etc. as new problems without any additional
workup and the physician orders a prescription, the visit often equates to a
level 4 visit. When I used the self-limited category, the visit equates to a level
3, which we believe is more in line with the physician's work.
Answer
# 6. The 1995 and the 1997 DGs have a table the provider can use in
determining the level of MDM. There is no specific "new problem"
category. The examples you give of cold, otitis media, insect bite would lend
themselves to a minimal level of risk for the present problem. The number of
possible diagnosis and/or the number of management options your provider
considers is based on the number and types of problems addressed during the encounter,
the complexity of establishing a diagnosis and the management decisions that
are made by the physician. The highest level of risk in any one category
determines the overall risk.
Question
# 7. What information in a physician's note for a clinic/office visit
would constitute a plan of care?
Answer
# 7. A plan of care identifies the clinical decisions made by the
practitioner to treat the patient's condition. The documentation could include
the patient's diagnosis, the long-term treatment goals, the type, amount,
duration, and frequency of services, and any medications and/or test ordered.
The physician establishes the plan prior to treatment and makes adjustments as
needed for changes in the patient's condition.
Question
# 8. The 1995 and 1997 DG show "prescription drug management" in
the Moderate level of risk. Do I have to write a new prescription to qualify
for this level of risk?
Answer
# 8. A new prescription is not required for this level. The medical record
documentation must show you are either writing a new prescription for the
patient or evaluating any current prescriptions, including determining whether
the drug, dosage, and frequency are still appropriate for the patient's
condition.
Question
# 9. What is the difference between "prescription drug
management" for the moderate level of risk and "Drug therapy
requiring intensive monitoring for toxicity" in the high level of risk?
Answer
# 9. Prescription drug management is where a provider is either writing a
new prescription for the patient or evaluating any current prescriptions,
including determining whether the drug, dosage, and frequency are still
appropriate for the patient's condition. Intensive monitoring for toxicity is
evaluating the possible harmful effects of a toxin or poison prescribed for or
used on the patient. The most common example is chemotherapy drugs.
Question
# 10. For an established patient, must the MDM be one of the "two out
of three" components used to choose the procedure code?
Answer
# 10. WPS Medicare cannot find any information that would require the MDM
to be one of the two components used to choose the procedure code. However, a
former medical director has asked: "if not using the MDM, how are you
showing the medical necessity for the service?" If you can answer that
question through your medical record documentation by using the other two
components; history and exam, then the MDM would not be required.