Accurately Score MDM in the ED

By Sarah Todt, RN, CPC, CEDC

Determining MDM using the 1995 Documentation Guidelines for Evaluation and Management Services and directions from CPT® Evaluation and Management (E/M) Services Guidelines poses unique challenges when coding emergency medicine E/M services.

Evaluation and Management – CEMC

The three key components used in the emergency department (ED) for assigning E/M services include: history, exam, and MDM. MDM dictates the highest service level that may be reported and the history and physical exam documentation needed to support the choice.

MDM: The Driving Force

There are four levels of MDM to support the five ED E/M codes:

  • Straight forward (99281)
  • Low (99282)
  • Moderate (99283 and 99284)
  • High (99285)

Determine the MDM level by reviewing three distinct components. The entire record must be reviewed and all information considered.

CPT® references the following three components for MDM:

1. Number of diagnosis and management options

2. Amount and complexity of data

3. Risk

Many coders or auditors reference MDM scoring modeled after a Marshfield Clinic-type audit tool. The scoring is not part of official documentation guidelines, with the exception of the Table of Risk. The audit tool gives some components a numerical value to help the coder or auditor determine the appropriate level.

For more information on assigning E/M ED leveling, see the article “Evaluate Your Performance When ED Leveling” by Jim Strafford, CEDC, MCS-P, in this issue of Coding Edge.

Number of Diagnosis and Management Options

The “number of diagnosis and management options” component of MDM considers the range of diagnoses and the treatment that may be required. Audit tools score this component based on if a patient is established or new, and if there is additional work-up planned. CPT® does not distinguish between new and established patients for ED E/M service codes. Most ED patients are considered new.

Scoring for number of diagnosis or management options:

New patient no additional work-up planned 3 points
New patient with additional work-up planned 4 points

 

The definition of “additional work-up planned” has not been defined clearly within the audit tool, and there are many interpretations available. Most audit tools reference (at a minimum) admissions, transfers, and scheduled diagnostics or physician follow-up for additional work-up planned.

Amount and Complexity of Data

The “amount and complexity of data” component is referred to as the “data point” component of MDM. This component gives value to diagnostic tests and other information essential for determining the management of the patient’s illness. Components to consider include: diagnostic tests, obtaining or reviewing old records, discussion with other providers, independent visualization of image or tracing, and obtaining history from someone other than the patient.

The components have a numeric value of one or two points. The points obtained are added for a final score in this area.

Amount and Complexity of Data Points
Clinical labs test ordered or reviewed

1

CPT® Medicine section test—ordered/reviewed

1

CPT® Radiology section test—ordered/reviewed

1

Discuss patient results with performing physician

1

Decision obtain old records or additional hx other than pt

1

Review/summarize data old records/add hx other than pt

2

Independent interpretation of an image, tracing, specimen

2

 

Table of Risk

The Table of Risk is an official part of the 1995 Documentation Guidelines for Evaluation and Management Services and is applicable to all specialties. Coders are instructed to assign risk based on the highest intervention in any category of the risk table. The three categories include:

1. Presenting Problem

2. Diagnostic Procedure(s) Ordered

3. Management Options Selected

Generally, for ED coding, the interventions listed in the “diagnostic procedure(s) ordered” will not lead to the highest element for risk.

Example of risk elements typically used for ED MDM:

MINIMAL LOW MODERATE HIGH
Suture removal (placed at other facility) OTC med only;

acute uncomplicated injury or illness

Rx management;

Acute illness with systemic symptoms;

Acute complicated injury;

Exacerbation of chronic condition

Abrupt neuro change;

Potential life threatening illness; Severe exacerbation of chronic illness; Medications requiring monitoring;

Parenteral controlled medications

 

Overall Scoring of MDM

Each of the three MDM areas should be scored. The level is determined by selecting the highest two of the three distinct areas.

Number of Dx and Mgt Options Amount and Complexity of Data Risk Level of MDM
1 1 Minimal Straight forward
2 2 Low Low
3 3 Moderate Moderate
4 4 High High

 

Nature of Presenting Problem

The nature of the “presenting problem” is not considered a key component of scoring MDM; however, it may provide essential information needed to determine appropriate levels of service. In the current environment of electronic health records (EHRs) and templated records, documentation tools are engineered to encourage optimal documentation. To ensure proper code assignment, take the nature of the presenting problem into consideration—especially with moderate MDM supporting both 99283 and 99284.

CPT® provides the following language:

99283   Emergency department visit for the evaluation and management of a patient, which requires these 3 key components: An expanded problem focused history; An expanded problem focused examination; and Medical decision making of moderate complexity. Counseling and/or coordination of care with other providers or agencies are provided consistent with the nature of the problem(s) and the patient’s and/or family’s needs. Usually, the presenting problem(s) are of moderate severity.

99284   Emergency department visit for the evaluation and management of a patient, which requires these 3 key components: A detailed history; A detailed examination; and Medical decision making of moderate complexity. Counseling and/or coordination of care with other providers or agencies are provided consistent with the nature of the problem(s) and the patient’s and/or family’s needs. Usually, the presenting problem(s) are of high severity, and require urgent evaluation by the physician but do not pose an immediate significant threat to life or physiologic function.

Cases scoring as moderate MDM may range from an illness that requires a prescription at discharge to an illness that requires labs, X-rays, and parenteral medications. For example, a patient diagnosed with conjunctivitis and discharged with a prescription for eye drops, and a patient with abdominal pain treated with parenteral medication after diagnostic evaluation including a computed tomography (CT) scan and lab work, would both support moderate MDM. If both cases are documented with a detailed history and exam, the coder will now need to consider the nature of presenting problem to assign the appropriate level: 99283 or 99284.

Final Level Assignment

As mentioned, MDM dictates the highest level that may be assigned and the history and exam must support the assignment. With a good understanding of the components, you can assign the MDM level accurately and appropriately. Consider these two cases as examples:

Case History 1

History of Present Illness

The patient is a 9-year-old female who presents with dry cough that started last night with low grade fever and malaise. Pt. also complains of right ear pain, duration lasting one day(s). The course is constant.

Cough quality: moderate, dry and barking cough. Pt. otherwise active and talkative, and sounds happy. The degree of severity is mild.

Tylenol® given for fever with relief.

Review of Systems

Genitourinary symptoms: Negative.

Musculoskeletal symptoms: Negative.

Neurologic symptoms: Negative.

Lymphatic symptoms: Negative.

Skin symptoms: Negative, but no rash.

Other review of systems: All systems reviewed as documented in chart.

Past medical history: Negative.

Physical Examination

General appearance: No acute distress, alert, smiling, interactive and body habitus is well-nourished.

Skin: Warm. Dry. No pallor.

Ears, nose, mouth, and throat: Oral mucosa moist. No pharyngeal erythema or exudate. Ear: Right tympanic membrane red.

Neck: Supple, no tenderness.

Heart: Regular rate and rhythm, no extra heart sounds.

Respiratory: Respirations non-labored. Lungs: Clear to auscultation. equal bilateral, no stridor no wheezes.

Chest wall: No tenderness.

Abdominal: Soft.

Neurological: Alert.

MDM

Differential diagnosis:

Wheezing, upper respiratory infection, otitis

Impression and Plan

Diagnosis:

URI, otitis media

Discharge plan

Condition: Stable.

Dispositioned: To home.

Prescriptions: Prescription order.

Pharmacy: amoxicillin 250 mg/5 mL oral liquid (Ordered): 5 mL, PO, BID, 7 day(s), 70 mL

MDM Scoring

Number of diagnosis and management options: New patient, no additional work-up = 3 points

Amount and complexity of data: none = 0 points

Risk: Prescription management = moderate

Total MDM: Moderate

History and exam: Detailed

This case could support either a 99283 or 99284 based on moderate MDM. The coder needs to evaluate the nature of the presenting problem. This case would be more consistent with the moderate severity, supporting a 99283.

Case Example 2

History of Present Illness

The patient is a 4-year-old female who presents with dry cough that started last night with fever of 104 and malaise. She has not voided in 12 hours and parents report that she has decrease in PO intake. Pt. also complaining of right ear pain, duration lasting 1 day(s). The course is constant.

Cough quality: Moderate, dry and barking cough. The degree of severity is mild.

Tylenol® given for fever with relief.

Review of Systems

Genitourinary symptoms: Negative.

Musculoskeletal symptoms: Negative.

Neurologic symptoms: Increased tiredness.

Lymphatic symptoms: Negative.

Skin symptoms: Negative, but no rash.

Other review of systems: AIl systems reviewed as documented in chart.

Past medical history: Negative.

Physical Examination

General appearance: No acute distress, slightly lethargic, and body habitus well-nourished.

Skin: Warm. Dry. No pallor.

Ears, nose, mouth, and throat: Oral mucosa moist. No pharyngeal erythema or exudate. Ear: Right tympanic membrane red.

Neck: Supple, no tenderness.

Heart: Regular rate and rhythm, no extra heart sounds.

Respiratory: Respirations non-labored. Lungs: Clear to auscultation. Equal bilateral, no stridor no wheezes.

Chest wall: No tenderness.

Abdominal: Soft.

Neurological: Alert.

MDM

Differential diagnosis:

Wheezing, upper respiratory infection, otitis

Orders

Labs: CBC, Chem 7, UA

Chest X-ray

IV NS 250 cc bolus

 

Reassessment

Pt. much improved after bolus. Afebrile. Parents agree to discharge.

Impression and Plan

Diagnosis:

Bronchitis, otitis media, mild dehydration

Discharge plan

Condition: Stable.

Dispositioned: To home.

Prescriptions: Prescription order.

Pharmacy: Amoxicillin 250 mg/5 mL oral liquid (Ordered): 5 mL, PO, BID, 7 day(s), 70 mL

MDM Scoring

Number of diagnosis and management options: New patient, no additional work-up = 3 points

Amount and complexity of data = 2 pts

Risk: Prescription management = moderate

Total MDM: Moderate

History and exam: Detailed

The nature of presenting problem for this case appears much higher than in Case 1. Both cases would be scored with moderate MDM and detailed history and exam; however, Case 2 would support the higher code choice 99284, based on an urgent nature of presenting problem.

 

Sarah Todt, RN, CPC, CEDC, is the director of compliance and physician education for MRSI, Inc., an industry leader in emergency medicine coding and reimbursement. Sarah has served on AAPC’s National Advisory Board (NAB) and Emergency Department Specialty Exam Steering Committee and has published several ED-related articles in Coding Edge.

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