Determine Decision-making Complexity for Maximum Pay

To ensure evaluation and management (E/M) service charges are safe from auditor scrutiny, infectious disease (ID) physicians should use the same method to determine the complexity of medical decision-making as the auditors use, says Cindy Parman, CPC, CPC-H, principal of Coding Strategies, a coding consulting firm in Dallas, Ga., and a CPT faculty member of the American Medical Association (AMA).

Auditors, who are generally FBI agents with limited clinical knowledge, use a scoring system to determine whether the services provided justify the complexity of medical decision-making an ID physician claims when he or she bills for an E/M service. Most physicians, however, do what I call the coding dance, says Parman. They apply an E/M code that feels right.

Sally Trew, RN, CPC, a medical reimbursement consultant with Alpern, Rosenthal & Co., a Pittsburgh accounting firm that provides healthcare consulting services, agrees. If you dont use a point system, youre putting yourself at risk of upcoding and having to pay back money and being assessed fines, Trew says.

Medical decision-making refers to the complexity of establishing a diagnosis or selecting treatment options, or both. CPT 2000 instructs physicians to use the following three areas to help determine the complexity of medical decision-making:
The number of possible diagnoses and/or the number of management options that must be considered;
The amount and/or complexity of medical records, diagnostic tests and/or other information that must be
obtained, reviewed and analyzed; and
The risk of significant complications, morbidity, and/or mortality, as well as co-morbidities associated with the patients presenting problem, the diagnostic procedures and/or the possible management options.

To characterize medical decision-making as highly complex, physicians need to prove two of the following: extensive number of diagnoses or management options, extensive review of data, or high risk of complications, morbidity or mortality. To prove moderate complexity, physicians must show two of the following: multiple diagnoses or treatment options, moderate review of data, and moderate risk of complications.

The Scoring System

A scoring system is the best way to take the guesswork out, Parman says. She recommends using the same scoring system government auditors and Medicare carriers use to score decision-making. Except for the determination of risk, the point system is used to score the complexity of medical records and test reviews and the number of diagnoses. Risk of complications and co-morbidities is determined by using a table of risk, which categorizes levels of risk as minimal, low, moderate and high.

Scoring four points or more in both categories warrants a high-complexity decision-making claim, or scoring at least four points in any one of the two elements along with proving high risk of complications also warrants a high-complexity medical decision-making claim.

Assuming a comprehensive history and comprehensive examination are performed and [...]

- Published on 2000-06-01