Evaluate Medical Decision Making in the Emergency Department
Guidelines and auditing tools help with the decision-making process involved in coding E/M services.
Selecting evaluation and management (E/M) service levels in the emergency department (ED) can be a challenge, and the medical decision making (MDM) component is particularly difficult to score. E/M service guidelines are defined separately in the CPT® code book, by the Centers for Medicare & Medicaid Services (CMS) in the 1995 and 1997 Documentation Guidelines for Evaluation and Management Services, and by Medicare Administrative Contractors (MAC). A review of the various payer definitions and audit tools for scoring MDM will help you code E/M services in the ED, quickly and easily.
MDM Scoring Is Consistent Across Guidelines
All scoring methods consider the same three components of MDM, as defined in CPT® and CMS’ documentation guidelines:
- The number of diagnosis or management options that must be considered;
- The amount and/or complexity of medical records, diagnostic tests, and other information that must be obtained, reviewed and analyzed; and
- The risk of significant complications, morbidity, as well as comorbidities, and mortality associated with the patient’s presenting problem(s), the diagnostic procedures(s), and the possible management options.
MDM scoring is categorized into four types: straightforward, low, moderate, and high. All types require two of the three components to be met for all ED E/M services, regardless of the source or tool.
Shortly after the 1995 Documentation Guidelines for Evaluation and Management Services was published, the Marshfield audit tool was created to assist coders in valuing components of E/M. Although not a formal part of CMS’ documentation guidelines, some MACs, such as First Coast, National Government Services (NGS), Novitas, and Palmetto GBA, have created audit tools/score sheets that include a Marshfield-like audit tool. These tools provide definitions and values for the different components of MDM. Other MACs, such as CGS, Noridian, and WPS, do not use a specific tool, but reference information that focuses primarily on medical necessity. And some payers reference CPT® or other guidelines.
Number of Diagnoses or Management Options
To get to know the three components to MDM better, let’s first discuss the number of diagnosis or management options.
The ED E/M codes do not distinguish between “new” or “established.” Because patients present to the ED for unscheduled, episodic, emergent conditions, most are considered a new patient with a new problem to the examiner. As such, using a standard score sheet, most are considered either “new problem to the examiner, without additional work-up” (three points), or “new problem to the examiner, with additional work up” (four points). For nearly all MACs, the definition of “additional work-up” includes any diagnostic study performed during the ED evaluation, qualifying most patients for the four points in this area.
The American College of Emergency Physicians (ACEP) has also published Frequently Asked Questions (FAQs) in support of this position, stating, “When a treating physician in the ED orders diagnostic testing, consultation, or a referral while the patient is in the Emergency Department, ‘additional work-up’ has been planned and performed.”
For example, using the tool shown in Table A, four points are awarded for a patient presenting with new onset chest pain requiring a workup with labs, a chest X-ray, and electrocardiogram (EKG).
Score the number of diagnoses or management options.
|Self-limited or minor (stable, improved, or worsening||Max = 2||1|
|Established problem (to patient); stable, improved||1|
|Established problem (to patient); worsening||2|
|New problem (to patient); no additional workup planned||Max = 1||3|
|New problem (to patient); add workup planned||4|
Amount and Complexity of Data
The second area of MDM is the amount and/or complexity of medical records, diagnostic tests, and other information that must be obtained, reviewed, and analyzed (e.g., data points). This section is generally consistent with the categories and scoring audit tools/score sheets.
In the scoring of data, one point is given for each of the following:
- Review and/or order of clinical lab tests
- Review and/or order of tests in the Radiology section of CPT®
- Review and/or order of tests in the Medicine section of CPT®
- Decision to obtain old records or the history from someone other than the patient
Two points are given for:
- Review and summary of old records and/or the history obtained from someone other than the patient and/or discussion of the case with another healthcare provider
- Independent visualization of image, tracing, or specimen
For example, using the tool shown in Table B, a total of five points are scored with the order of lab tests (1 point), order of an X-ray (1 point), a discussion with the radiologist regarding the X-ray (1 point), and a summary of old medical records (2 points).
Four points are scored for the order of lab tests (1 point), order of medicine test – EKG (1 point), and independent visualization of tracing EKG interpretation (2 points).
Table B: Score the amount and complexity of data.
|Review and/or order of clinical lab tests||1|
|Review and/or order of tests in the radiology section of CPT||1|
|Review and/or order of tests in the medicine section of CPT||1|
|Discussion of test results with performing physician||1|
|Decision to obtain old records and/or obtain history from someone other than patient||1|
|Review and summarization of old records and/or obtaining history from someone other than patient and/or discussion of case with another healthcare provider.||2|
|Independent visualization of image, tracing or specimen itself (not simply review of report)||2|
The final category of MDM includes the risk of significant complications, morbidity, as well as comorbidities, and mortality associated with the patient’s presenting problem(s), the diagnostic procedures(s), and the possible management options — otherwise known as “risk.” This component is further defined in the Table of Risk in the 1995 Documentation Guidelines for Evaluation and Management Services, and typically consistent throughout most score sheets/audit tools.
The Table of Risk, shown in Table C, breaks down the three components of the presenting problem(s), diagnostic procedure(s) ordered, and management options selected. The highest scoring element determines the level of risk, regardless of category. When scoring risk for ED E/M services, the categories for presenting problem(s) and management options typically score the highest. For example, a patient who receives intravenous (IV) Dilaudid for pain control would score as high risk for parenteral controlled substance.
Table C: Use the Table of Risk to determine the level of risk.
- Acute illness with systemic symptoms (presenting problem) – e.g., fever or hives
- Acute complicated injury (presenting problems) – e.g., fracture or facial laceration
- Prescription management (treatment option) – e.g., antibiotics
- One or more chronic illness with severe exacerbation, progression or side effect of treatment (presenting problem) – e.g., chronic obstructive pulmonary disease (COPD) exacerbation
- Acute or chronic illnesses or injuries that may pose a threat to life or bodily function (presenting problem) – e.g., chest pain
- Abrupt change in neurological status (presenting problem) – e.g., dizziness
- Parenteral controlled substances – e.g., intramuscular (IM)/IV Dilaudid
- Drug therapy requiring intensive monitoring for toxicity – e.g., Cardizem
Put It All Together
The final determination for MDM is made by the highest two components of the number of diagnoses or treatment options, amount and complexity of data, and risk, as shown in Table D. If the highest two are in the same type, that will determine the level. If the highest two score into two different types, the lower type of the two will determine the score.
Number of diagnosis or management options: 4 points
Data: 3 points
Overall MDM: High
Number of diagnosis or management options: 4 points
Data: 2 points
Overall MDM: Moderate
Table D: Add up the components.
|A||Number diagnoses or treatment options||≤ 1 Minimal||2 Limited||3 Multiple||≥ 4 Extensive|
|B||Amount and complexity of data||≤ 1 Minimal||2 Limited||3 Moderate||≥ 4 Extensive|
|Type of decision making||Straight- Forward||Low Complexity||Moderate Complexity||High Complexity|
For accurate coding in the ED, be aware of the definitions and scoring methodologies available for scoring E/M services and, specifically, the MDM component.
Do you want to solidify your knowledge in E/M and ED coding? Consider obtaining these two AAPC certifications:
Certified Evaluation and Management Coder (CEMC™)
Certified Emergency Department Coder (CEDC™)
AAPC Coder has an MDM tool that can help you determine the type of decision making.
AAPC Coder, E/M Calculator https://coder.aapc.com/emcalculator/index
NGS audit tool: www.ngsmedicare.com/ngs/wcm/connect/ngsmedicare/3632a905-b697-4266-8fc0-2aa2a84fedb2/1074_0317_EM_Documentation_Training_Tool
ACEP FAQs: www.acep.org/administration/reimbursement/reimbursement-faqs/medical-decision-making-and-the-marshfield-clinic-scoring-tool-faq
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