Internal Medicine Coding Alert
Tally Your Risk the Way the Auditors Do
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5 must-have answers will aid you in MDM selection You can quantify your internist's medical decision-making (MDM) level to protect your practice if you use a risk management chart. Problem: Navigating the chart, however, can prove difficult. Here are some FAQs to get you started. What Is the Table of Risk? CMS published the Table of Risk as one of seven tables in the 1995 and 1997 E/M Documentation and Coding Guidelines. Medicare providers are supposed to use the tables to calculate the history, exam and medical decision-making types, says Robert W. White, a practice administrator in Goldsboro, N.C. The table of risk (presenting problem, diagnostic procedures ordered, and management options selected) is one of three preliminary tables, which you can use along with the problem categories table and the type-of-data table, to determine the level of decision-making, White says. "The results of the history, exam and the decision-making tables are then entered into a seventh table to determine the code level to bill." Other versions exist as well. The AMA published a version of the table of risk in 1999. Carriers may have their own interpretations. Why Should I Use the Sheets? In the event of an audit, using the table of risk and the associated tables will provide support for your internist's code selection. You can also use the charts as a self-audit tool to check your physician's levels. Use the original CMS scoring sheets when performing internal audits or selecting code levels. "CMS just announced that comprehensive error rate testing (CERT) reviews are done using the 1995 and 1997 guidelines, not the carrier revised criteria," said Bill Dacey, MPH, MBA, CPC, in "E/M Auditing" at the 2007 AAPC National Conference in Seattle. Watch out: You might have to use a different audit tool for some carriers. For instance, TrailBlazer (Medicare Part B carrier for Texas, Virginia, Maryland and Delaware) has developed its own counting system available at http://www.trailblazerhealth.com/Publications/Job%20Aid/coding%20pocket%20reference.pdf. How Does Risk Tie Into
? MDM comprises three elements:
To qualify for a given type of decision-making (straightforward, low complexity, moderate complexity, and high complexity), the physician must meet or exceed two of the three elements, according to CPT E/M services guidelines.
(For more information on proving medical necessity for E/M services, see http://www.trailblazerhealth.com/Publications/Job%20Aid/medical%20necessity.pdf.)
How Should I Evaluate Type?
You can't read your internist's mind to figure out all the work he performed in determining a patient's plan. On the other hand, he can help you see what was involved by completely documenting the process.
"In the assessment, include all diagnoses and any suspected problems or concerns, including rule-outs," Dacey says.
Don't overlook: You won't code the rule-outs, but documenting them shows a more involved MDM type.
What Should I Look for?
To weigh the type of risk, zoom in on three items. Identify each problem's
You can map these to the CMS medical point-making system, which includes a table for the number of diagnoses or treatment options, the amount and/or complexity of data reviewed, the table of risk, and a summary scoring sheet (get the Highmark BCBS standard one at http://www.highmarkmedicareservices.com/partb/reference/pdf/scoresheets/8985.pdf -- see page 2).
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