This discussion is limited to office or other outpatient services for new or established patients. Office or outpatient implies that the treatment is given in the practice office or other ambulatory facility, and that the patient has not been admitted to a healthcare facility.
Drawing the Lines of E/M Care
The key components that determine the level of E/M service are history taken at the time of visit, extent of physical examination and medical decision-making. Medical decision-making is generally the area that causes the most confusionjust what are the differences between straightforward (S), low (L), moderate (M) and high complexity (H) medical decision-making?
Medical decision-making refers to the complexity of establishing a diagnosis and/or selecting a management option as measured by the:
1. number of possible diagnoses and/or management options;
2. amount and/or complexity of medical records, diagnostic tests and/or other information that is obtained, reviewed and analyzed; and
3. risk of significant complications, morbidity and/or mortality including co-morbidities associated with
the patients presenting problem(s), diagnostic
procedure(s) and/or the possible management options.
When selecting the overall complexity of medical decision-making, two of these three elements must be met or exceeded to qualify for a given type of medical decision-making.
The Risk Factor
There is also a final element in medical decision-making and that is risk. A risk table developed by the Health Care Financing Administration (HCFA) and the American Medical Association (AMA) determines the level of risk based on the highest level of risk in any of the three following categories.
1. Presenting problem(s) and disease process:
MinimalMinor problem (follow-up to treated vaginal yeast infection)
LowStable chronic illness (high blood pressure under control with medication)
ModerateUndiagnosed new problem (patient normally healthy complaining now of burning urination and blood in urine)
HighThreat to life or bodily function (ectopic pregnancy)
2. Diagnostic procedure(s) ordered:
LowSuperficial needle biopsy
ModerateDeep needle or incisional biopsy
HighDiagnostic laparoscopy with risk factors
3. Management option(s) selected:
LowOver-the-counter (OTC) drugs (e.g., cough medicine, Pepcid AC), application of vaginal medication
ModeratePrescription drug management (e.g., HRT, blood pressure medication), rectocele repair in a patient who is basically otherwise healthy, or
endoometrial biopsy on a patient with a heart condition
HighRuptured ectopic pregnancy, hysterectomy on a patient who has high blood pressure and is morbidly obese
Ob/Gyn Case Examples
Straightforward medical decision-making: A female patient is in for follow-up to urinary tract infection (due to E. coli). She is no longer having symptoms, but a urine culture is performed just to be sure and it is negative. The physician starts the patient on prophylactic Macrodantin.
This is an example of straightforward medical decision-making because this is an established problem that is stable (minimal diagnostic options), one test is performed (minimal data reviewed), and a prescription is written (moderate risk). Two out of three elements met equates to straightforward medical decision-making.
Low complexity medical decision-making: The patient was being seen as a follow-up to a complaint of hot flashes and had been previously put on Estrace and medroxyprogesterone. At this visit, the physician decided to increase her Estrace, but continued with the current level of medroxyprogesterone. She is to be followed up as needed.
This is an example of low complexity medical decision-making because this is an established problem that is worsening (limited diagnostic options), no data was reviewed (minimal to none), and risk is moderate (prescription management). Two of three elements are needed to select the level of medical decision-making so, per the table, the level is low.
Moderate medical decision-making: The patient presents with pelvic bloating, burning and leaking of urine. The physician orders lab work and a screening ultrasound and plans on following up with the patient in two weeks to discuss the results.
This is moderate complexity of medical decision-making. This is a new problem with additional work-up planned (the lab work and follow-up visit which make for extensive diagnostic options), the physician ordered lab tests and an ultrasound (limited data), and the risk is moderate due to the new, undiagnosed problem. This leads to a moderate level of decision-making.
High medical decision-making: Since we limited this discussion to outpatient services for a new or established patient, the likelihood of high-complexity medical decision-making at the outpatient level is fairly low. An example of E/M service at this level would include a female patient with a history of cardiac complications who is now being monitored and treated for ovarian cancer. Due to the multiple tests being ordered, the complexity of diagnosis, risk of morbidity and risk of complications due to the other medications the patient is taking (for the cardiac problems), this would easily qualify as a high level of medical decision-making.
Also, any emergency, life threatening situation requiring immediate surgery or hospitalization would equate to high risk decision-making (e.g., a patient coming to the office with a ruptured ectopic pregnancy and requiring immediate hospitalization).
Documentation is the KeyAgain
As Witt indicates in the information provided here, the greatest emphasis should be placed on the complexity of the medical decision-making when determining E/M levels. Thomas Kent, CMM, principal of Kent Medical Management in Dunkirk, Md., concurs. Management options and the number of diagnoses are where documentation usually fails, says Kent. This is especially true in moderate to high-risk cases. You cant use diagnosis codes for what you rule out, Kent continues, but you can document what you were thinking. By writing down how you arrived at your medical decision, you present a much stronger case for a level four or five E/M visit. The medical complexity is expressed through this thorough documentation.
Kent says that time is not usually the most relevant factor in the majority of medical encounters, although CPT has specific guidelines for the amount of time spent between doctor and patient. Though it is essential for physicians to spend enough face-to-face time with the patient to obtain a thorough understanding of the presenting problem, Kent says A lot of doctors undercode because they do not appreciate the complexity of the work theyre doing. Time is there as an override for those situations when more than 50 percent of the time was spent in counseling the patient.
In ensuring that your practice codes appropriately and also gets the highest level of reimbursement, impress upon physicians and the clinical staff the need to write down everythingas Kent saysnot just what diagnosis was determined, but what was ruled out. Dont expect the individuals reviewing your claims to read between the lines. Explicit documentation will ease the way to hassle-free reimbursements.