Step 2 Use the Medical Decision-Making Table
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- Nathaniel Hill
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1 Step 2 Use the Medical Decision-Making Table In Step 1, we determined the patient location and patient type. For most patient encounters, this determines the first 4 digits of the 5-digit CPT code. Three components of the service determine the fifth digit: history, examination, and medical decision making. The order of these components is not random. This logical sequence of patient evaluation is taught in medical school and used in practice. First, detailed questions are asked about the chief complaint and about relevant medical problems (a history is taken). Second, a physical examination pertinent to the history is performed. After these data are gathered, a diagnosis is made and a treatment plan is formulated ( medical decision making ). The printed materials from AMA and CMS follow this well-known sequence. This approach, however, is not the best way to understand and logically apply E/M codes. For the purposes of E/M coding according to CMS guidelines, history and examination are simply checklists of questions asked or examination components performed. It is a relatively simple matter to tally the number of items completed and determine the level of service provided. The medical decision-making component, however, has its own set of three subcomponents or elements. These three items must be ranked to determine the degree of medical 15 TPE_02.indd 15
2 16 Practical Evaluation and Management Coding decision-making complexity involved. The result is that the appropriate level of medical decision making is the most difficult of the three components of the fifth digit of the CPT code to determine. While medical decision making is the most complicated component to determine according to CMS guidelines, it is actually the piece of E/M coding that should be the most intuitive. CPT describes medical decision making as straightforward, low complexity, moderate complexity, and high complexity. Without further definition of the above terms, it is probably obvious to the experienced practitioner how these terms should apply to common patient complaints for any given practice. That is, while the medical decision-making component is the most difficult to determine according to CMS guidelines, it is actually the component for which the correct level is the most obvious and intuitive based on patient presentation. Once the medical decision-making component has been determined, the history and examination can then be tailored to the appropriate level of service. Primarily for these reasons, my method of determining correct E/M codes rearranges the traditional order of patient evaluation and makes determining the medical decision making component Step 2. History and examination are then considered sequentially in Step 3. Applying this revised order of thinking to several patient presentations that are routine in your practice is the key to understanding and accurately applying E/M codes. To determine the degree of complexity of medical decision making, consider three elements: (1) number of diagnoses or management options, (2) amount and/or complexity of data to be reviewed, and (3) risk of complications and/or morbidity or mortality. Each of these elements will be graded on a 4-point scale. As we consider each of these elements, we will construct a grid. Once we have scored each element, the two TPE_02.indd 16
3 Step 2. Use the Medical Decision-Making Table 17 highest ranking items will determine the degree of complexity involved. The number of diagnoses or management options are described by AMA and CMS as minimal, limited, multiple, or extensive. The CMS Guidelines recognize that a greater number of diagnoses considered and more management options available would contribute to the complexity of medical decision making. Furthermore, management of established diagnoses is less complex than the management of diagnoses. Comorbid conditions affect the level of medical decision making if they are directly related to the diagnosis in question (or if they increase the risk of morbidity or mortality). The first row of the Medical Decision-Making Grid looks like this: Diagnosis and management options: Minimal, self-limited, minor, stable Limited, worsening Multiple, problem, no Extensive, problem, The amount and/or complexity of data to be reviewed is also described as minimal or none, limited, moderate, or extensive. Data review may include laboratory testing, radiographic studies, review of old medical records, and obtaining a history from someone other than the patient. Discussion with the physician who performed the test and personal review of images previously interpreted by another physician are indicators of increased complexity and should be documented. The CMS Guidelines indicate that some type of result positive, noncontributory, an exact value, and so on is necessary, whereas simply TPE_02.indd 17
4 18 Practical Evaluation and Management Coding documenting data reviewed without elaboration is inadequate. With the addition of Data Review, the Medical Decision-Making Grid now looks like this: Diagnosis and management options: Data review: Minimal, self-limited, minor, stable Minimal/ none Limited, worsening Limited (e.g. 1 image or lab/test) Multiple, problem, no Moderate (e.g. 1 image + lab/test) Extensive, problem, Extensive (e.g. 2 images) The risk of complications and/or morbidity or mortality is graded minimal, low, moderate, or high. Risk may be associated with the diagnosis itself (Presenting Problem), the diagnostic procedures required for confirmation of the diagnosis (Diagnostic Procedures Ordered), and the anticipated management options (Management Options Selected). Invasive procedures and surgery increase the amount of risk involved. Any interventions performed on an urgent basis also increase the amount of risk involved. The CMS Guidelines include a table with common clinical examples to help guide the assessment of risk (Table 2.1). The CMS Table of Risk includes examples of presenting problems, diagnostic procedures, and management options that are reflective of minimal, low, moderate, or high risk. The highest level of risk in any one of these three categories is considered the risk of complications and/or morbidity or mortality for the E/M encounter. TPE_02.indd 18
5 Step 2. Use the Medical Decision-Making Table 19 Table 2.1. CMS Table of Risk. Presenting Problem(s) One self-limited or minor problem, e.g. cold, insect bite, tinea corporis Two or more selflimited or minor problems. One stable chronic illness, e.g. well controlled hypertension, noninsulin dependent diabetes, cataract, BPH. Acute Uncomplicated illness or injury, e.g. cystitis, allerhic rhinitis, simple sprain. One or more chronic illnesses with mild exacerbation, progression, or sideeffects of treatment. Two or more stable chronic illnesses. Undiagnosed problem with uncertain prognosis, e.g. lump in breast. Acute illness with systemic symptoms, e.g. pyelonephritis, pneumonitis, colitis. Acute complicated injury, e.g. head injury with brief loss of conciousness. Level of Risk Minimal Low Moderate High One or more chronic illnesses with severe exacerbation, progression, or side effects of treatment. Acute or chronic illness or injuries that pose a threat to life or bodily functions, e.g. multiple trauma, acute MI, pulmonary embolus, severe respiratory distress, progressive severe rheumatoid arthritis, psychiatric illness with potential threat to self or others, peritonitis, acute renal failure. (continued) TPE_02.indd 19
6 20 Practical Evaluation and Management Coding Diagnostic Procedure(s) Ordered Laboratory testing requiring venipuncture. Chest x-rays. EKG/EEG. Urinalysis. Ultrasound, e.g. echocardiography. KOH prep. Physiologic tests not under stress, e.g. pulmonary function tests. Noncardiovascular imaging studies with contrast, e.g. barium enema. Superficial needle biopsies. Clinical laboratory tests requiring arterial puncture. Skin biopsies. Physiologic tests under stress, e.g. cardiac stress test, fetal contraction stress test. Diagnostic endoscopies with no identified risk factors. Deep needle or incisional biopsy. Cardiovascular imaging studies with contrast and no identified risk factors, e.g. arteriogram, cardiac catheterization. Obtain fluid from body cavity, e.g. lumbar puncture, thoracentesis, culdocentesis. Level of Risk Minimal Low Moderate High Cardiovascular studies with contrast with identified risk factors. Cardiac electrophysiological tests. Diagnostic endoscopies with identified risk factors. Discography. TPE_02.indd 20
7 Step 2. Use the Medical Decision-Making Table 21 Management Options Selected Rest. Gargles. Elastic bandages. Superficial dressings. Over-the-counter drugs. Minor surgery with no identified risk factors. Physical therapy. Occupational therapy. IV fluids without additives. Minor surgery with identified risk factors. Elective major surgery (open, percutaneous, or endoscopic) with no identified risk factors. Prescription drug management. Therapeutic nuclear medicine. IV fluids with additives. Closed treatment of fracture or dislocation without manipulation. Level of Risk Minimal Low Moderate High Elective major surgery (open, percutaneous, or endoscopic) with identified risk factors. Emergency major surgery (open, percutaneous, or endoscopic). Parenteral controlled substances. Drug therapy requiring intensive monitoring for toxicity. Decision not to resuscitate or to de-escalate care because of poor prognosis. TPE_02.indd 21 9/3/2007 9:59:14 AM
8 22 Practical Evaluation and Management Coding With the addition of the level of risk of complications and/or morbidity or mortality the Medical Decision Making Grid now looks like this: Diagnosis and management options: Data review: Risk of complications/ M&M: MEDICAL DECISION MAKING Minimal, self-limited, minor, stable Minimal/ none Limited, worsening Limited (e.g. 1 image or lab/test) Multiple, problem, no Moderate (e.g. 1 image + lab/test) Extensive, problem, Extensive (e.g. 2 images) Minimal Low Moderate High Straight- Forward Low Moderate High When using the Table of Risk, the single highest level of risk in any row determines the overall score. However, when using the Medical Decision Making Grid immediately above, each row must be scored, and it is the lower of the two highest scores that determine the overall complexity of medical decision making. Several examples follow: Example 1. Diagnosis and management options = low complexity, data review = straight-forward complexity, risk of complications/m&m = moderate complexity. The two highest scores are low complexity and moderate complexity. The lower of these two scores is low complexity. Therefore, the overall level of medical decision making is low complexity. TPE_02.indd 22 9/3/2007 9:59:14 AM
9 Step 2. Use the Medical Decision-Making Table 23 Diagnosis and management options: x (lower of two highest scores) Data review: X Risk of complications/ M&M: x MEDICAL DECISION MAKING Straight- Forward Low Moderate High Example 2. Diagnosis and management options = moderate complexity, data review = moderate complexity, risk of complications/m&m = high complexity. The two highest scores are moderate complexity and high complexity. The lower of these two scores is moderate complexity. Therefore, the overall level of medical decision making is moderate complexity. Diagnosis and management options: x Data review: x (lower of two highest scores) Risk of complications/ M&M: x MEDICAL DECISION MAKING Straight- Forward Low Moderate High TPE_02.indd 23 9/3/2007 9:59:14 AM
10 24 Practical Evaluation and Management Coding The correct level of medical decision making can be determined by following the steps detailed above. This is the most complicated component of E/M coding, but it is also the most closely associated to the presenting complaint. It is most easily mastered by applying this approach to the most common patient presentations in your practice. Once you have determined the level of medical decision making, the final pieces of the correct E/M code are easily assembled. TPE_02.indd 24 9/3/2007 9:59:14 AM
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