Medical Decision Making — E/M Coding Documentation and Guidelines


Determining the level of Medical Decision
Making. The new E&M video is fantastic for determining
the level of MDM. Itís described very well so I just want to give a shout out for that. Laureen: Yeah, thatís the CEU Webinar that
sheís talking about thatís pending getting CEU approval. But in the Blitz videos, I do
cover E&M coding but because itís 2 days where Iím doing this review Blitz and E&M
codes are only 10 of the 150 questions on the exam, I canít spend as much time as I
would like to teaching it. So on the CEU one, itís 3 hours. Itís more expanded and Alicia
wrote the CEU quiz for me. So she had her students watch it and I guess it was helpful
so thatís good. Alright, so where Iím going is in your CPT
manuals, there is a Medical Decision Making table in your E&M guidelines. And it happens
to be on page 10. And of course, this is just 1/3 of the E&M you know, when youíre coding
by the history exam and Medical Decision Making. And as you can see, I like to mark things
up and make it more visual. I actually drew a line and made them look like columns because
thatís what they are. To the far right is the score, if you will, or the level of Medical
Decision Making. So youíve got straight-forward, low, moderate,
and high. The first column is what I call DMO for number of diagnoses or management
options. And then choices you have are minimal, limited, multiple, extensive. And Medical
Decision Making is one of the most nebulous areas of E&M to try and score. And youíve
probably seen E&M scoresheets that they and help quantify these things. But for purposes
of the board exam, youíre not bringing in an audit tool so you are going to have to
use this language ñ minimal, limited, multiple, extensive. Like for me, okay, Iím like, ìminimal
versus limitedî. They sound pretty similar to me so what youíll typically find is they
count 1, 2, 3, 4. Itís for one diagnosis for management option, limited is for two,
etcetera. For the second column, data, itís amount
and or complexity of data to be reviewed. So the types are minimal or none, limited,
moderate, extensive. So those are the choices there. When theyíre talking about data, it
could be them reviewing an x-ray or reviewing reports from a test that was run or lab results.
Anything like that is reviewing of data. Again, on those score sheets for Medical Decision
Making, theyíve got this whole little point system on how they add it up. You know, was
the test in the radiology section? Was it test from the lab section? And they kind of
come up with a scoring system to figure out if itís minimal, limited, moderate or extensive.
On the board exam, they tend to give you the words, the language to plugin. The 3rd column is risk. Risk of complications
and or morbidity or mortality. So thereís minimal, low, moderate, or high risk and there
is a table of risk that if you Google it, you know, E&M Table of Risk. Itís on the
CMS website. It is a set table and it will have a bunch of things listed. Like for example,
prescription meds. If a prescription is given, itís automatically a moderate risk, if the
physician wrote a prescription. Minimal would be something like go home and gargle or rest,
that kind of thing. So you get the idea. High would be like theyíre recommending elective
surgery or something like that. So what you do is once you have the words
or the levels of DMO, data and risk, we need to do our leveling for 2 of 3. Because when
you read the guidelines up above what Iíve highlighted here, it says, ìTo qualify for
a given type of decision making, 2 of 3 elements in table 1Öî which is what weíre looking
atÖ ìmust be met or exceeded.î So letís see how that shakes out. If you have aÖ let me move this over a little
bit. Letís say, a multiple for DMO, a limited for data, and a moderate for risk. So, multiple
which shows up on the moderate level of complexity, limited which shows up on the low level and
moderate, which shows up on the moderate level. So basically, a moderate, low, moderate. We
can throw out the lowest. When itís 2 of 3, throw out the lowest code to the next lowest.
So weíre going to throw out the limited or the low complexity and that leaves us with
moderate complexity Medical Decision Making. So thatís how you could you know, do that
on the board exam. If you had aÖ letís just say, a limited
high which translates to a low, low, high, we can throw out one of the lows but the next
lowest remains a low so itís low complexity. So we can throw out one but not two. And thatís
how 2 of 3 you know, leveling works. It works in the Medical Decision Making table and it
works with the overall E&M level scoring. So thatís Medical Decision Making in a nutshell
there. Thereís more information in your guidelines. So you can see here, determine the complexity
of Medical Decision Making and these bullets correspond to those 3 columns that we were
just looking at. So DMO is the number of possible diagnoses
with the number of management options that must be considered. And remember, Medical
Decision Making is whatís going in the physicianís head toÖ after theyíve already taken your
history, theyíve talked about review of systems, theyíve done an exam based on that. Now,
theyíre going to put it all together and decide what to do about it. Are they going
to send you for physical therapy? Are they going to order tests? Is he going to write
a prescription? Okay? Data is the amount and or complexity of medical
records, tests, or other information that must be obtained, reviewed, and analyzed.
So it could be obtained. They might write an order for an x-ray. Thatís data. Or they
might review an x-ray in a subsequent visit. Thatís data, okay. Youíll also hear sometimes
with phone calls, when a physician will talk to a patient on the phone. If they document
that phone call, they canít get credit for it that day. But when they come back for the
next visit, if they review that phone call conversation, that can count toward data. And then this third one, risk. The risk of
significant complications, morbidity and or mortality, as well as co-morbidities associated
with the patientís presenting problems, the diagnostic procedures and or the possible
management options. And some of it seems a little duplicative when you look at the Table
of Risk and itís like, ìWell, itís talking about diagnoses. Isnít that in the DMO, the
number of diagnoses and management options?î And yes, it is. But when you start breaking
it down and doing it often enough, it makes sense. But keep in mind, for the board exam, youíre
not going to need to know how to do it from like an auditorís perspective. Now if youíre
going for the E&M specialty credential, they let you bring in an audit tool. And I share
a really good one on the E&M you know, webinar that you can use in your day to day coding.
Itís actually modified from a Medicare webinar I went to years ago. But itís all in one
page which is kind of nice. Get more cpc exam tips, medical coding training
and CEU credits. Go to www.codingcertification.org

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