Ob-Gyn Coding Alert

One of the most important ingredients for success in todays medical market is the ability to accurately and legally code for the level of services you are providing your patient. Much of coding is fairly straightforward, and simply requires finding the right code to match the procedure or service performed. What is not that simple is coding for Evaluation and Management (E/M) Services, and in particular, the key area of medical decision-making.

According to senior consultant and coding expert Cynthia Thompson, CPC, of Gates, Moore & Company, a medical practice management consulting firm, Medical decision-making is one of the hardest areas of E/M services to grasp and do well. Even with the enforcement of the new E/M guidelines delayed until July 1998, and significant pressure being brought by the specialty societies to change them, Thompson believes coders in ob/gyn practices would do well to strengthen their understanding of medical decision-making in the current guidelines. Its not going to go away, she states. Increasingly, you will need a grasp of the required documentation to code for higher levels.

The Role of Medical Decision-Making

What propels an E/M exam to a higher level of service is how much work, time, thinking, evaluation and risk are involved in the delivery of the service. This investment of effort and energy in providing a specific service is broken down into three key areas: 1) the examination, 2) history, and 3) medical decision-making. The more documented effort and energy invested in each of these areas, the better you can make the argument for coding to a higher level of service and being reimbursed at a higher rate.

Medical decision-making is really the pivot point of the whole process of evaluating and managing a patient. In this key step, the provider carefully looks at all the facts concerning the patient and makes decisions regarding diagnosis and selecting a course of management. The CPT ranks this process of establishing a diagnosis and deciding on a management strategy into four categories based on how complex the medical decision-making process is. These categories are:

1. Straightforward

2. Low Complexity

3. Moderate Complexity

4. High Complexity

To qualify for one of these four levels, the service provided must meet certain requirements in the following three areas:

1. the number of possible diagnoses and/or the number of management options that must be considered.

2. the amount and/or complexity of medical records, diagnostic tests, and/or other information that must be obtained, reviewed and analyzed.

3. the risk of significant complications, morbidity and/or mortality, as well as comorbidities associated with the:

a. patients presenting problem(s),

b. diagnostic procedures, and/or

c. possible management options.

The difficulty of medical decision-making, Thompson explains, is that these measurements are subjective and up to the providers judgement, but the important thing is to make sure your documentation is consistent with the level of coding you choose. The guidelines are designed to help you know what needs to be documented in each of these categories. If you record what is actually performed and then compare it to the chart, Thompson says, it will be clear which of the four categories to use.

Documenting the Diagnosis and Management Options

For each encounter, an assessment, clinical impression or diagnosis should be documented. For a presenting problem with an established diagnosis, the record should reflect whether the problem is improved, well controlled, resolving or resolved, or is inadequately controlled, worsening, or failing to change as expected. For a presenting problem without an established diagnosis, the assessment or clinical impression may be stated in the form of a differential diagnosis or, as a possible, probable, or rule out diagnosis. The initiation or change in treatment should be documented, as well as the who and where of any consultations.

Documenting the Amount and Complexity
of Data Reviewed

The guidelines demand that physicians specify in their documentation precisely what data they are collecting and reviewing. Diagnostic services such as lab tests and x-rays should be documented as well as the review of these results. The guidelines say, A simple notation such as WBC elevated or chest x-ray unremarkable is acceptable. Test results may be documented by simply initialing and dating the results. Decisions to talk with family members or caretakers about a patients history or obtain old records should also be documented. Relevant information found as a result of these efforts (or contrarily if nothing was found) should be noted. Discussions with physicians who have performed diagnostic tests on the patient should be noted, as should direct visualization and independent interpretation of an image, tracing or specimen.

Documenting the Risk of Significant Complications, Morbidity, and/or Mortality

Factors that increase the risk of complications, morbidity, and/or mortality should be documented. If a surgical or invasive procedure is scheduled or performed at the time of the E/M encounter, the type of procedure should be documented. Any referrals for surgical or invasive diagnostic procedures should also be documented.

Determining the level of risk takes into consideration all of the aspects of the service being provided:

1. the presenting problem(s),

2. the diagnostic procedure(s), and

3. the possible management options.

Risk is then determined at four levels:

1. minimal,

2. low,

3. moderate and

4. high.

Examples to Determine Risk The E/M Documentation Guidelines recognize that the determination of risk is complex and not readily quantifiable. Here are some common clinical examples from each level of risk: Minimal risk would include a minor presenting problem such as a cold, along with diagnostic procedures that may include a chest x-ray or a WBC and management options of rest. Low risk would include presenting problems such as two or more minor problems or a stable chronic illness (i.e. controlled hypertension) or an uncomplicated acute problem (i.e. cystitis). Diagnostic procedures would be physiologic non-stress tests, non-cardiovascular imaging and superficial biopsies. Management would be limited to minor surgery without risk factors, IVs or physical or occupational therapy. Moderate risk includes one or more chronic illness with mild exacerbation or two or more stable chronic illnesses. Moderate risks also could be an undiagnosed new problem such as a lump in the breast or an acute illness with systemic symptoms such as pyelonephritis, pneumonitis or colitis. Moderate risk might also be an acute, complicated injury with brief loss of consciousness. Diagnostic procedures could include such things as stress tests, diagnostic endoscopies (without identified risk factors), deep needle biopsies, cardiovascular imaging (without risk factors) and lumbar punctures. Management options for this level would include such things as minor surgery with risks, major elective surgery without risk factors, prescription drugs, IV medications or closed fracture management without manipulation. High risk would include everything not included up to this point. Examples would be chronic illness with severe exacerbation, life threatening injuries or illness or an abrupt change in neurologic status. Diagnostic procedures would include all high-risk procedures such as cardiovascular imaging with contrast and identified risk factors. Management options would include elective major surgery with risk factors, emergency major surgery, drug therapy requiring intensive monitoring for toxicity, or decisions not to resuscitate.