The Driving Parts 
of E/M Level Selection

By Katherine Abel, CPC, CPC-I, CMRS

In this three-part series on the driving components of level selection for the majority of evaluation and management (E/M) services, we discuss history, examination, and medical decision making (MDM). In this final installment, we’ll focus on the MDM component.

Evaluation and Management – CEMC

MDM is perhaps the most important of the three primary components of E/M code selection. It is also the most subjective. Whether you use the 1995 or 1997 E/M documentation guidelines, the nature of the presenting problem and the medical necessity of the encounter are the best MDM indicators. You will choose an overall MDM level based on three factors: the number of diagnoses or management options; the amount and/or complexity of data to be reviewed; and the risk of complications and morbidity or mortality.

Count Diagnoses or Management Options

The number of diagnoses or management options is based on the relative difficulty level in making a diagnosis, and the status of the problem. Although audit tools vary, the number of diagnosis and management options is typically determined using a points system. Under this system, points are assigned according to not only how sick a patient is, but the amount of physician work involved.

  • Minor problems, such as those that would resolve regardless if the patient had sought medical attention, are worth one point. A patient may have four minor, documented problems. But for coding purposes only a maximum of two such problems can be counted.
  • Established, stable, or improved conditions are worth one point each.
  • Established, worsening conditions are worth two points each.
  • A new problem (new to the patient or new to the provider) without any additional workup is worth three points. You may only count such a problem once per encounter, even if there are multiple occurrences in the encounter.
  • A new problem with additional workup is counted as four points.

A workup is defined as anything the physician had to do after making the diagnosis the patient left with on that day. For example, if the physician suspects a particular diagnosis and sends the patient on for a diagnostic test to confirm that suspicion, that diagnostic test would count as workup.

There are four levels of MDM defined by CPT®, and four corresponding diagnosis and treatment level options:

Straightforward MDM requires a minimal number of diagnosis and treatment options which correlate to (at least) a detailed work level. For both the 1995 and 1997 documentation guidelines, the number of diagnosis and management options is minimal if the sum is one point.

Low MDM requires a limited number of diagnosis or treatment options. For both the 1995 and 1997 documentation guidelines, the number of diagnosis and management options is low if the sum is two points.

Moderate MDM requires a moderate number of diagnosis and treatment options. For both the 1995 and 1997 documentation guidelines, the number of diagnosis and management options is moderate if the sum is three points.

High MDM requires an extensive number of diagnoses or treatment options. For both the 1995 and 1997 documentation guidelines, the number of diagnosis and management options is high if the sum is four or more points.

For example, a level four new patient visit (99204 Office or other outpatient visit for the evaluation and management of a new patient, which requires these 3 key components: A comprehensive history; A comprehensive examination; Medical decision making of moderate complexity) requires a moderate level of MDM. To meet the work of moderate MDM, a moderate number of diagnosis and/or treatment options (three points total) must be documented.

Point to Data Amount and Complexity

The amount and complexity of data for review is measured by the need to order and review tests, and the need to gather information and data. Planning, scheduling, and performing clinical labs and tests from the medicine and radiology portions of CPT® are indications of complexity, as is the need to request old records, or to obtain additional history from someone other than the patient (such as a family member, caregiver, teacher, etc). Documented discussions with the performing physician about unusual or unexpected patient results may also result in credit.

If a physician makes an independent visualization and interpretation, for example, with an MRI film or a Gram stain—and he or she is not billing separately for that service—it would be credited in this component of code selection.A points system is very effective for measuring the amount and complexity of data for review:

  • Clinical labs ordered or reviewed are worth one point.
  • Any test(s) reviewed/ordered from the medicine section of the CPT® book are worth one point.
  • Any procedures reviewed/ordered from the radiology section of the CPT® are worth one point. Regardless of the number of radiological procedures reviewed/ordered, only a total of one point may be assigned (e.g., five radiology reports reviewed count as one point only).
  • Discussing patient’s results with the performing or consulting physician is worth one point—if it is captured in the documentation.
  • Decisions to obtain old records or additional history from someone other than the patient are worth one point.
  • Review and summary of data from old records or additional history gathered from someone other than the patient is worth two points.
  • Independent or second interpretation of an image tracing or specimen is worth two points. Note that this means not just the review of the report, but of the actual film image or tracing.

There are four MDM levels defined by CPT®, and four corresponding data amount and complexity levels:

Straightforward MDM requires a minimal amount and complexity of data. For both the 1995 and 1997 documentation guidelines, the amount and complexity of data is straightforward if the sum of this data is zero or one point.

Low MDM requires a limited amount and complexity of data. For both the 1995 and 1997 documentation guidelines, the amount and complexity of data options is low if the sum is two points.

Moderate MDM requires a moderate amount and complexity of data. For both the 1995 and 1997 documentation guidelines, the amount and complexity of data options is moderate if the sum of this data is three points.

High MDM requires an extensive amount and complexity of data. For both the 1995 and 1997 documentation guidelines, the amount and complexity of data options is high if the sum is four or more points.

For example, a level four new patient visit (99204) requires a moderate MDM level. To meet the work of moderate MDM, a moderate amount and complexity of data (three points) must be documented.

Turn to the Table of Risk

Risk is measured based on the physician’s determination of the patient’s probability of becoming ill or diseased, having complications, or dying between this encounter and the next planned encounter. Risk indications include the nature of the presenting problem, the urgency of the visit, co-morbid conditions, and the need for diagnostic test for surgery.

Documentation guidelines determine the risk level using the Table of Risk. The Table of Risk is divided into three columns; each column correlates with an overall risk level. The three columns list presenting problems, diagnostic procedures ordered, and management options selected.

There are four levels of MDM defined by CPT®, and four corresponding risk levels:

Straightforward MDM requires a minimal risk level. For both the 1995 and 1997 documentation guidelines, a straightforward level or risk corresponds with any of the columns in the Table of Risk that are labeled “minimal risk.”

Low MDM requires a low risk level. For both the 1995 and 1997 documentation guidelines, a low level or risk corresponds with any of the columns in the Table of Risk that are labeled “low risk.”

Moderate MDM requires a moderate risk level. For both the 1995 and 1997 documentation guidelines, a moderate level or risk corresponds with any of the columns in the Table of Risk that are labeled “moderate risk.”

High MDM requires a high risk level. For both the 1995 and 1997 documentation guidelines, a high level or risk corresponds with any of the columns in the Table of Risk that are labeled “high risk.”

For example, a level four new patient visit (99204) requires a moderate risk level. To meet the work of moderate MDM, a moderate level or risk (as determined using the Table or Risk) must be documented.

Elements Drive Overall MDM Level

To select an overall MDM level, at least two of 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) for that level must be met.

For example, moderate complexity MDM requires two of the following three elements:

  • Multiple diagnoses or management options (a total of three points when using the points system described in this article)
  • Moderate amount and/or complexity of data to be reviewed (a total of three points when using the points system described in this article)
  • Moderate risk of complications and/or morbidity or mortality, as defined by the Table of Risk.

Next month in Coding Edge, we’ll pull together all the information on history, exam, and MDM we’ve reviewed to illustrate proper reporting of overall E/M level selection in various outpatient and inpatient settings.

table-of-risk

Katherine Abel, CPC, CPC-I, CMRS, is the director of curriculum for the AAPC.

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One Response to “The Driving Parts 
of E/M Level Selection”

  1. Madeline Murphy says:

    Ms Abel:

    Is there any CMS reference to MDM as being the most important of the three primary components of E/M code selection and therefore, one which should be used when determining LOS for established visits. I am trying to find a source for a policy committee. Thank you

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