Otolaryngology Coding Alert

Most folks in the business of documenting and reporting how healthcare providers spend their time are familiar with the levels of medical decision making (MDM) table in CPT^®. However, the table has a reputation for being subjective and sometimes confusing, even for experienced evaluation and management (E/M) coders.

“You can have a chronic illness with exacerbation, but if you don’t tell me the severity of the exacerbation in the documentation, I have to assume moderate. The treatment plan should correspond with the notes about severity of exacerbation,” says Swartzwelder. In other words, if your provider’s notes are not clear in this regard, use this as an opportunity for education, at best, and a query, at least.

Don’t Stumble Over ‘Amount and/or Complexity of Data’

The Amount and/or Complexity of Data to Be Reviewed and Analyzed column is notorious for giving coders pause. Understanding the complexity of data often requires medical knowledge, which is why the provider’s documentation is so important. If the notes aren’t clear enough for you to accurately use this column to assign a level to the encounter, you should query the provider. However, if the information doesn’t affect the level, don’t let it derail you.

For example, let’s say that based on problems addressed and risk, you have a solid 99215 (Office or other outpatient visit for the evaluation and management of an established patient … high level of medical decision making. When using total time on the date of the encounter for code selection, 40 minutes …). Remember, you only need two out of the three elements, which means you can sometimes level the encounter without the data element.

“I wouldn’t spend time calculating data unless it was going to mean the difference between one level and another that was medically necessary,” advised Rae Jimenez, CPC, CDEO, CIC, CPB, CPMA, CPPM, CCS, senior vice president of products at AAPC, in her presentation “2021 E/M Lessons Learned,” at HEALTHCON 2022.

That’s not to say you should overlook opportunities for provider education when it comes to the data element. However, try to separate that from the information that’s truly needed to level an encounter accurately.

“I see coders and auditors playing the ‘well, if’ game. Well, if the chronic condition was severe, and these labs were not billed separately, it would be high MDM. ‘Well, if’ is an efficient way to discuss the data element and educate providers, but inefficient for coding,” says Swartzwelder.

Expert tip: “Zoom out to see the larger picture. The entire encounter should flow and be consistent with the level of service selected. No element of MDM should drastically alter the overall level of service,” explains Swartzwelder.

Remember That Risk of Complications Refers to the Plan

Like the Data element, the Risk of Complications and/or Morbidity or Mortality element is multifaceted. The important thing to remember is that the word “risk” refers to the management plan (diagnostic procedures, treatments, etc.), not the patient’s symptoms and general condition.

Consider what the CPT^® E/M guidelines state:

“The assessment of the level of risk is affected by the nature of the event under consideration. For example, a low probability of death may be high risk, whereas a high chance of a minor, self-limited adverse effect of treatment may be low risk. Definitions of risk are based upon the usual behavior and thought processes of a physician or other qualified health care professional in the same specialty.”

In other words, the clinician defines the risk of complication or morbidity based on the circumstances, and while quantification is not necessarily required, you may want to establish an ongoing dialogue with the provider so you can better understand their thought process. If the provider doesn’t clearly indicate level of risk, without clarification you should default to the lowest level to avoid compliance risk.