E&MCODING: SCORE MEDICALE&MCODING: SCORE MEDICAL
DECISION MAKING THE WAYDECISION MAKING THE WAY
AN AUDITORWILLAN AUDITORWI...
What Is the Table of Risk?What Is the Table of Risk?
 1 of 7 tables in the 1995 and 1997 E/M
Documentation and Coding Gui...
Why Should I Use the Sheets?Why Should I Use the Sheets?
 provide support for your physician’s code
selection
 self-audi...
How Does RiskTie Into MDM?How Does RiskTie Into MDM?
 Medical decision-making (MDM)
comprises three elements:
 Number of...
How Should I Evaluate Type?How Should I Evaluate Type?
 You can’t read your physician’s mind
 They can help you see what...
What Should I LookFor?What Should I LookFor?
 To weigh the type of risk, zoom in on 3
items.
 Diagnosis
 Status
 Risks...
Score MDMLike a Pro -- Here’sScore MDMLike a Pro -- Here’s
HowHow
 You code it:
 An ENT sees a patient with a diagnosis ...
Classify Problem’s Status UsingClassify Problem’s Status Using
Table 1Table 1
 Follow these rules:
 If the ENT has previ...
Classify Problem’s Status UsingClassify Problem’s Status Using
Table 1Table 1
 Why is there a point difference?
 CMS exp...
Classify Problem’s Status UsingClassify Problem’s Status Using
Table 1Table 1
 Is the problem self-limited or minor?
Exam...
Self-Limited or MinorSelf-Limited or Minor
 Defined as:
 “A problem that runs a definite and
prescribed course, is trans...
Classify Problem’s Status Using TableClassify Problem’s Status Using Table
11
 CMS guidelines state,
 “The assessment of...
Example:Example:
 An established male patient previously diagnosed as a controlled-
diabetic presents with complaints of ...
Calculate Reviewed Data PointsCalculate Reviewed Data Points
Going back to our previous ENT OM case study:
You code it:
An...
 The ENT did not review any data so he receives a
0 in this table.
 Remember to map your CPT codes to the areas
listed i...
 If the physician is coding the service like an x-ray,
allergy testing, or an ENG at this service or
another, they are al...
 Frustrated with the extra time associated with
E/M services that involve an interpreter or
require a translator?
 The K...
Table of RiskTable of Risk
 Determining the ENT scenario’s level of risk
¤ minimal ¤ low ¤ moderate ¤ high ¤
 Here’s how...
 To get started classify the level of these
elements:
 Presenting problem(s)
 Diagnostic procedures ordered
 Managemen...
Lookto History forProblemLookto History forProblem
DetailsDetails
 OMPatient
 Should you classify OM with a decision for...
Count Tests/Labs to ClassifyCount Tests/Labs to Classify
Column 2Column 2
 To calculate the diagnostic procedures level,
...
Check Hx When Weighing SurgeryCheck Hx When Weighing Surgery
RiskRisk
 Best bet: Before selecting the management
options ...
Jump to ‘High’ forRiskJump to ‘High’ forRisk
ExceptionsExceptions
 Table lists “diagnostic endoscopies with no identified...
Jump to ‘High’ forRiskJump to ‘High’ forRisk
ExceptionsExceptions
Do this: Usually give a physician moderate risk credit f...
Circle ‘Moderate’ forWeighingCircle ‘Moderate’ forWeighing
Medication RiskMedication Risk
 Givingsamples involves this sa...
Circle ‘Moderate’ forWeighingCircle ‘Moderate’ forWeighing
Medication RiskMedication Risk
 What Counts as Prescription/Dr...
Circle ‘Moderate’ forWeighingCircle ‘Moderate’ forWeighing
Medication RiskMedication Risk
 Where Do OTC Instructions Fall...
Identify RiskLevel With HighestIdentify RiskLevel With Highest
CircleCircle
 In our OM case the physician’s diagnosis of ...
Obtain Final Complexity ResultObtain Final Complexity Result
 To tally your whole MDM, enter the 3 tables’ scores in the ...
Obtain Final Complexity ResultObtain Final Complexity Result
 Tally: Because the scenario involves two circles in one
col...
How would you score a case in whichHow would you score a case in which
no column had two circles?no column had two circles...
How would you score a case in whichHow would you score a case in which
no column had two circles?no column had two circles...
Putting History, Exam, MDMPutting History, Exam, MDM
TogetherTogether
Example:
Whe n a patie nt co m e s into the o ffice
...
 Choose level based on the medically necessary
history, exam, and medical decision making (MDM)
that is performed and doc...
Breakdowns:
 Assuming chest pain is a new problem, you would
receive 4 points in the "Number of Diagnoses or
Treatment Op...
 Indicate in your question that these scenarios do not involve
performing a complete ROS, which a comprehensive history
r...
 Now if you examine 8 or more systems -- such
as constitutional, eyes, ENT, detailed cardio,
respiratory, skin, neurologi...
Save the Date!Save the Date!
Next Webinar will feature our OB coding guru,
Suzanne Leder!
Written OB Coding Alert coached ...
Supercoder.com
Em score-medical-decision-making
Em score-medical-decision-making
Em score-medical-decision-making
Em score-medical-decision-making
Em score-medical-decision-making
Em score-medical-decision-making
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Em score-medical-decision-making

  1. 1. E&MCODING: SCORE MEDICALE&MCODING: SCORE MEDICAL DECISION MAKING THE WAYDECISION MAKING THE WAY AN AUDITORWILLAN AUDITORWILL TALLY YOUR MDM THE WAY THE AUDITORSTALLY YOUR MDM THE WAY THE AUDITORS DODO Jen Godreau, BA, CPC, CPEDCJen Godreau, BA, CPC, CPEDC Co nte nt Dire cto rCo nte nt Dire cto r Inhe althcare ’s Supe rco de rInhe althcare ’s Supe rco de r je nnife rg @ supe rco de r. co mje nnife rg @ supe rco de r. co m
  2. 2. What Is the Table of Risk?What Is the Table of Risk?  1 of 7 tables in the 1995 and 1997 E/M Documentation and Coding Guidelines.  1 of 3 preliminary tables that you can use along with the problem categories table and the type of data table, to determine the level of decision-making
  3. 3. Why Should I Use the Sheets?Why Should I Use the Sheets?  provide support for your physician’s code selection  self-audit tool to check your physicians’ levels  Watch out: You might have to use a different audit tool for some carriers.  TrailBlazer (Medicare Part B carrier for Texas, Virginia, Maryland and Delaware) has developed its own counting system
  4. 4. How Does RiskTie Into MDM?How Does RiskTie Into MDM?  Medical decision-making (MDM) comprises three elements:  Number of diagnoses or management options  Amount and/or complexity of data to be reviewed  Risk of complications and/or morbidity or mortality  To qualify for a given type of decision- making the physician must meet or exceed 2 of the 3 elements
  5. 5. How Should I Evaluate Type?How Should I Evaluate Type?  You can’t read your physician’s mind  They can help you see what was involved by completely documenting the process  include all diagnoses and any suspected problems or concerns, including rule-outs  Don’t overlook: You won’t code the rule-outs, but documenting them shows a more involved MDM type.
  6. 6. What Should I LookFor?What Should I LookFor?  To weigh the type of risk, zoom in on 3 items.  Diagnosis  Status  Risks, treatments or management You can map these to the CMS medical point-making system.
  7. 7. Score MDMLike a Pro -- Here’sScore MDMLike a Pro -- Here’s HowHow  You code it:  An ENT sees a patient with a diagnosis of otitis media (OM) and decides the patient requires tubes. The physician orders no tests and reviews no records. The patient is scheduled for tympanostomy (69436, Tym pano sto m y [re q uiring inse rtio n o f ve ntilating tube ], g e ne ralane sthe sia ).
  8. 8. Classify Problem’s Status UsingClassify Problem’s Status Using Table 1Table 1  Follow these rules:  If the ENT has previously treated the patient for OM, CMS considers the problem established and awards 2 points for an established problem that is inadequately controlled, worsening or failing to progress as expected  If this is the first time the ENT is treating the patient for OM, you should consider the diagnosis a new problem, which is worth three points
  9. 9. Classify Problem’s Status UsingClassify Problem’s Status Using Table 1Table 1  Why is there a point difference?  CMS expects that the decision-making for a known problem is less than that of a new problem  Who is the problemnew to?  The sheet indicates “to the examiner”. The problem has to be new to that provider. The increased score for a new problem is given because working up a new problem involves more work than assessing a problem that is established or familiar to the physician.
  10. 10. Classify Problem’s Status UsingClassify Problem’s Status Using Table 1Table 1  Is the problem self-limited or minor? Examples of self-limited or minor on Table of Risks  Cold  Insect Bite  Tinea Corporosis  For cases involving a self-limited or minor problem you still count the problem’s status as self-limited or minor and assign it 1 point, rather than giving it 3 points
  11. 11. Self-Limited or MinorSelf-Limited or Minor  Defined as:  “A problem that runs a definite and prescribed course, is transient in nature, and is not likely to permanently alter health status OR has a good prognosis with management/compliance.”
  12. 12. Classify Problem’s Status Using TableClassify Problem’s Status Using Table 11  CMS guidelines state,  “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.”  Risk measures the chance of the patient becoming worse from the time he leaves the physician’s care to the next visit.  A common cold carries minimal risk, consistent with the definition of a minor or self-limited problem.
  13. 13. Example:Example:  An established male patient previously diagnosed as a controlled- diabetic presents with complaints of a runny nose and congestion without any other symptoms.  Ignoring the co morbidities and listing only the presenting problem diagnosis ,will make the visit qualify for the lowest risk level.  The physician should also consider the effect the patient’s diabetes has on management options, and if the physician treats the condition, they should report 250.00 (Diabe te s m e llitus witho ut m e ntio n o f co m plicatio n; type IIo r unspe cifie d type , no t state d as unco ntro lle d) for addressing the underlying disease.  Documentation guidelines state, “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 should be documented.”
  14. 14. Calculate Reviewed Data PointsCalculate Reviewed Data Points Going back to our previous ENT OM case study: You code it: An ENT sees a patient with a diagnosis of otitis media (OM) and decides the patient requires tubes. The physician orders no tests and reviews no records. The patient is scheduled for tympanostomy (69436, Tym pano sto m y [re q uiring inse rtio n o f ve ntilating tube ], g e ne ral ane sthe sia).
  15. 15.  The ENT did not review any data so he receives a 0 in this table.  Remember to map your CPT codes to the areas listed in the Amount and/or Complexity of Data Reviewed table.  Give 1 point for clinical lab tests like urinalysis or a strep test. (80000 series codes) Don’t miss: The table counts medicine tests (90000 codes) separately. If a physician reviews an x-ray and orders an ECG, give 1 point for each of these tests. Calculate Reviewed Data PointsCalculate Reviewed Data Points
  16. 16.  If the physician is coding the service like an x-ray, allergy testing, or an ENG at this service or another, they are already receiving credit for the review in the test code.  Give points for work the physician could not otherwise get credit for.  ei: a strep test that an outside lab is reading or an x- ray that an outside radiologist reads  “Do not report [E/M] services for test interpretation and report.” Don’t Double Dip!Don’t Double Dip!
  17. 17.  Frustrated with the extra time associated with E/M services that involve an interpreter or require a translator?  The Key – Get your physician to write “Poor historian” and then record who the historian is and why the patient is not giving the history. Example: Cases involving a babysitter attempting to give the history for a small child. If time doesn’t dominate these encounters qualifying them for time-based coding, consider giving a point in this table for “decision to obtain history from someone other than parent.” Calculate Reviewed Data PointsCalculate Reviewed Data Points
  18. 18. Table of RiskTable of Risk  Determining the ENT scenario’s level of risk ¤ minimal ¤ low ¤ moderate ¤ high ¤  Here’s how: Select the risk level based on the single highest element identified in the table of risk’s three columns (1 of 3). Do not need one element in each column. Instead assign the patient’s risk using one element in the one column that represents the highest level.
  19. 19.  To get started classify the level of these elements:  Presenting problem(s)  Diagnostic procedures ordered  Management options selected Table of RiskTable of Risk
  20. 20. Lookto History forProblemLookto History forProblem DetailsDetails  OMPatient  Should you classify OM with a decision for tubes as a presenting problem that is stable chronic (low), acute uncomplicated illness (low), or acute illness with systemic symptoms (moderate)?  If there is documented hearing loss, balance dysfunction, speech/language delay, tympanic membrane rupture, you could argue that it represents an acute or chronic illness that may pose a risk to loss of function, classifying the presenting problem as high.
  21. 21. Count Tests/Labs to ClassifyCount Tests/Labs to Classify Column 2Column 2  To calculate the diagnostic procedures level, you’ll focus on any workup the Otolaryngologist ordered.  Because the physician in the OM case study did not order or review any diagnostic procedures, you have no circle in column two.
  22. 22. Check Hx When Weighing SurgeryCheck Hx When Weighing Surgery RiskRisk  Best bet: Before selecting the management options level, check if the patient has any identified risk factors. This refers to the patient’s unique medical history that might affect the outcome.  If the patient in our case has asthma, you would circle "minor surgery with identified risk factors," instead of "minor surgery with no identified risk factors," upping this category’s level from low to moderate.
  23. 23. Jump to ‘High’ forRiskJump to ‘High’ forRisk ExceptionsExceptions  Table lists “diagnostic endoscopies with no identified risk factors” as moderate risk and “diagnostic endoscopies with identified risk factors” as high risk. Warning: Don’t increase the risk factor just because the patient’s undergoing a scope. “Does the fact that an endoscope procedure has risks associated with it make it a ‘high’ level for a diagnostic procedure ordered, or would the patient need to have a medical issue such as a recent heart attack to make it a ‘high’ level?”
  24. 24. Jump to ‘High’ forRiskJump to ‘High’ forRisk ExceptionsExceptions Do this: Usually give a physician moderate risk credit for ordering a scope. All patients undergoing an endoscopy face a certain amount of risk, so the ordering of the endoscopy is always the same. Exception: If a patient has an underlying health condition, such as a recent heart attack, that makes his service more questionable, you should increase the risk factor from “moderate” to “high”. Because the risk for that patient is increased, you should give the physician credit for “high” risk to represent ordering a diagnostic endoscopy for a patient who has identified risk factors.
  25. 25. Circle ‘Moderate’ forWeighingCircle ‘Moderate’ forWeighing Medication RiskMedication Risk  Givingsamples involves this sameprocess.  How Does CPT Weigh Managing Drugs?  The table of risk in the AMA-approved 1995 E/M guidelines lists prescription drug management as a common clinical example of moderate risk. The provider has to evaluate the suitability of the patient for the medication and weigh the benefits and risks.
  26. 26. Circle ‘Moderate’ forWeighingCircle ‘Moderate’ forWeighing Medication RiskMedication Risk  What Counts as Prescription/Drug?  Giving samples with or without a prescription all falls under prescription drug management. The process of prescription drug management would include giving the patient the actual meds as samples, the thought process and risk would remain the same as writing it down on a piece of paper. Example:  A female patient has allergic rhinitis. The allergist gives her samples of Astelin to try as needed. He tells the patient to call in for a prescription if she feels the prescription helps. This case constitutes prescription management.
  27. 27. Circle ‘Moderate’ forWeighingCircle ‘Moderate’ forWeighing Medication RiskMedication Risk  Where Do OTC Instructions Fall?  lower level of risk if the encounter involves only over the counter (OTC) meds. Risk assessment relates to the disease process anticipated between the present encounter and the next one.  If the patient had not been given prescription samples or had merely been instructed to use over-the-counter drugs, there would be less risk involved. The table of risk provides OTC drug management as an example of low risk.
  28. 28. Identify RiskLevel With HighestIdentify RiskLevel With Highest CircleCircle  In our OM case the physician’s diagnosis of chronic otitis media with effusion 381.3 (O the r and unspe cifie d chro nic no n-suppurative o titis m e dia) and documentation support a chronic illness with progression, and the child who is new to the ENT has no co morbidities.  Do your circles equate to low or moderate risk? You only need the 1 item for risk. Assign the level based on the highest circle.  The highest level is moderate. Therefore, the OM case has a moderate risk level.
  29. 29. Obtain Final Complexity ResultObtain Final Complexity Result  To tally your whole MDM, enter the 3 tables’ scores in the Final Result for Complexity table.  Determine the final score using 2 out of the 3 elements. Circle a "3" in the first row for a new patient with a worsening condition, "moderate" for the highest level of risk, and “≤ 1 Minimal" in the third row for no work-up ordered as follows:
  30. 30. Obtain Final Complexity ResultObtain Final Complexity Result  Tally: Because the scenario involves two circles in one column, you draw a line down that column, which classifies the case as moderate complexity. This level of medical decision-making can support a level-four new patient office visit (99204, O ffice o r o the r o utpatie nt visit fo r the e valuatio n and m anag e m e nt o f a ne w patie nt, which re q uire s the se thre e ke y co m po ne nts: a co m pre he nsive histo ry, a co m pre he nsive e xam inatio n and m e dicalde cisio n-m aking o f m o de rate co m ple xity ).
  31. 31. How would you score a case in whichHow would you score a case in which no column had two circles?no column had two circles?  The Highmark auditing score sheet instructs you if no column contains 2 or 3 circles to "draw a line down the column with the second circle from the left."  Example:  A patient has allergic rhinitis that’s usually controlled with Allegra-D but weather changes trigger the patient’s allergies, which precipitates her sinusitis. The patient’s sinusitis is a new problem to the pediatrician and he plans no additional work-up and orders no tests. The patient, an adolescent, gives her own history. The pediatrician has previously treated the patient’s allergies and writes her a prescription telling her to fill it if after she finishes the samples provided. She decides the Xyzal is decreasing her sinusitis and allergic rhinitis exacerbations.
  32. 32. How would you score a case in whichHow would you score a case in which no column had two circles?no column had two circles?  Under Number of Diagnoses or Treatment Options assign the sinusitis 3 points for a new problem with no work-up and the allergic rhinitis one point for an established, stable problem. The 4 points for diagnoses counts as extensive.  Give no points under Amount and/or Complexity of Data Reviewed. The teenager gives her own history, and the physician orders no tests. No data equals minimal or low.  Drawing a line down the column with the second circle from the left gives you moderate complexity MDM. A level 4 established patient office visit (99214, Office o r o the r o utpatie nt visit fo r the e valuatio n and m anag e m e nt o f an e stablishe d patie nt, which re q uire s at le ast two o f the se thre e ke y co m po ne nts: a de taile d histo ry, a de taile d e xam inatio n, and m e dicalde cisio n- m aking o f m o de rate co m ple xity …) contains MDM of moderate complexity.
  33. 33. Putting History, Exam, MDMPutting History, Exam, MDM TogetherTogether Example: Whe n a patie nt co m e s into the o ffice co m plaining o f che st pain, we o fte n o rde r lab wo rk, an ECG, and se nd the patie nt to the ho spital. The se instance s invo lve m o de rate to hig h risk but we do no t pe rfo rm a co m ple te re vie w o f syste m s (RO S) due to the pre se nting pro ble m ’s e m e rg e nt nature .  Willthe se be le ve l4 o r 5 e stablishe d patie nt o ffice visits?
  34. 34.  Choose level based on the medically necessary history, exam, and medical decision making (MDM) that is performed and documented at each encounter.  Probable combos for a patient presenting with a possible heart attack:  detailed history + detailed/comprehensive exam + mod/high MDM  Established patient visit requires 2 of 3 key components, the MDM, plus the amount of exam, may ultimately determine whether the encounter is a level 4 (99214) or 5 (99215). Answer:Answer:
  35. 35. Breakdowns:  Assuming chest pain is a new problem, you would receive 4 points in the "Number of Diagnoses or Treatment Options" area for the new problem to provider with additional work-up planned on the standard documentation worksheet.  You would receive a point for ordering lab work and a point for ordering the ECG for a total of 2 points in the "Amount and/or Complexity of Data to be Reviewed" section.  Because the diagnoses level puts you at a high level and the data amount is at a low level, the risk will determine whether the MDM is high complexity (if risk is high) or moderate complexity (if risk is moderate). MDMMDM
  36. 36.  Indicate in your question that these scenarios do not involve performing a complete ROS, which a comprehensive history requires.  History taking probably involves asking the patient about the severity, duration, quality, context, etc. of the pain (history of present illness [HPI]) and any past personal or family history of heart disease (past medical, family, social history [PFSH]). Therefore, your HPI will probably involve at least 4 (extended) HPI elements and 1 (pertinent) PFSH element.  At minimum ask questions about the constitutional and cardiac systems. Reviewing 2-9 systems (extended) counts as detailed ROS.  Extended HPI + extended ROS + pertinent PFSH = detailed history. History:History:
  37. 37.  Now if you examine 8 or more systems -- such as constitutional, eyes, ENT, detailed cardio, respiratory, skin, neurological, and psychological, you’ll be at a comprehensive exam.  If the severity didn’t allow for anything other than constitutional (vitals, general appearance) and detailed cardio, you may still be at a detailed exam. ExaminationExamination::
  38. 38. Save the Date!Save the Date! Next Webinar will feature our OB coding guru, Suzanne Leder! Written OB Coding Alert coached by every Ob coder’s favorite expert Melanie Witt. On April 20, Tuesday @ 12:00 EST Suzanne will be covering Icd-10 Coding Basics packed with OB, cardio, and other specialty examples.
  39. 39. Supercoder.com
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