• E&M Documentation Requirements, Part 5: Making Sense of Medical Decision-Making

    E&M documentation includes the history, exam and medical decision-making. Over the past few months, YO Info has taken a look at the three elements of the history as well as the exam. This month, we turn our focus to medical decision-making. Sometimes abbreviated to MDM, this part of documentation reflects the patient’s final diagnosis and progress as well as the response to and changes in the treatment plan. 

    This month, we turn our focus to medical decision-making. Sometimes abbreviated to MDM, this part of documentation reflects the patient’s final diagnosis and progress as well as the response to and changes in the treatment plan.

    The complexity of medical decision-making depends on three key components:

    1. Number of diagnosis and management options;
    2. Amount and/or complexity of data;
    3. Table of risk, which includes:
    4. Presenting problems;
    5. Diagnostic procedures ordered;
    6. Management options selected.

    Diagnosis and management options refer to the number of problems listed in the medical record. You should assign a status to each problem, defining its level of complexity:

    • Self-limited or minor — stable, improved or worsening;
    • Established problem — stable or improved;
    • Established problem — worsening;
    • New problem — no additional workup planned;
    • New problem — additional workup planned.

    Data focuses on the number and complexity of information sources you reviewed. Data listed in the chart can include a variety of items:

    • Clinical lab tests;
    • Diagnostic or radiological tests;
    • Discussions of tests with the performing physician;
    • Independent review of an image, trace or specimen;
    • Medical records obtained and reviewed from another provider or resource.

    You can order, review or request this data at the time of the service, so long as you document it in the medical record.

    The table of risk is broken down into three parts, each of which you should rate on a scale of minimal, low, moderate or high see below. The component with the highest level of risk determines the overall risk. Keep in mind that underlying diseases may only be considered if they significantly increase the complexity of medical decision-making.

    1. Presenting problems may be listed as self-limited problems, such as subconjunctival hemorrhage; a stable chronic illness, such as well-controlled glaucoma; an undiagnosed new problem with unknown prognosis; or a chronic illness with severe exacerbation.
    2. Diagnostic procedures may include a lab test requiring venipuncture; superficial needle biopsies; deep needle or incisional biopsies; and diagnostic endoscopies with identified risk factors.
    3. Management options may include rest; minor surgery with identified risk factors; prescription drug management; and elective major surgery with identified risk factors.

    Note: The Academy’s Ophthalmic Coding Series: Essential Topics includes both a charting tool and complete table of risk.

    Examples of Medical Decision-Making

    • Straightforward — Pseudophakic patient had no testing or data reviewed and will have cataract extraction/IOL in the left eye evaluated in three weeks. Patient continues current medication.
    • Low — Dry eye patient has a Shirmer tear test today and had temporary plugs in the two lower puncta inserted.
    • Moderate — Patient with dematochalasis had bilateral visual fields and external ocular photography today and is scheduled for a bilateral upper lid blepharoplasty.
    • High — Patient is diagnosed with macula-on retinal detachment and floaters, and visit included an extended ophthalmoscopy. The plan includes a letter to the referring MD, pneumatic retinopexy on the right eye today and retinal detachment-repair photocoagulation with drainage of subretinal fluid tomorrow.

    Physician Time

    Can time be considered a factor in choosing the level of service? Absolutely. When counseling and/or coordination of care constitutes more than 50 percent of the physician and patient/family encounter, then time may be considered the key or controlling factor to qualify for a particular level of E&M service.

    In such situations, you can only factor in time spent face to face with the physician, not time with allied health personnel or time in the office. Chart documentation should include the exact number of minutes spent in counseling. Issues you note counseling on might include: diagnostic results; impressions; prognosis; risks and benefits of management/treatment options; and importance of compliance. You should also note the chosen management or treatment options.

    After you have reviewed all components of medical decision-making, you can assess the level of complexity and move forward in choosing the most appropriate level of E&M service.

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    About the author: Jenny Edgar, CPC, CPCO, OCS, is the Academy’s coding specialist. Her 12 years of experience with coding and reimbursement includes certification as a compliance officer responsible for practice adherence with chart documentation and government relations. She oversees the Academy’s Chart Auditing Service and is a contributing author to the Ophthalmic Coding Coach and Ophthalmic Coding Series.