Otolaryngology Coding Alert

This case study hones your section 3 auditing skills You can nail down all the score sheet's fundamentals, but if you can't sort out low from moderate risk, you could end up under- or overcoding your ENT's MDM. In Otolaryngology Coding Alert 2008, Vol. 10, No. 3, we walked you through the audit tallying basics. See if you-ve got what it takes to score the following case's medical decision-making (MDM) using the standard CMS form. You code it: An ENT sees a patient with a diagnosis of otitis media (OM) and decides the patient requires tubes. The physician orders no tests and reviews no records. The patient is scheduled for tympanostomy (69436, Tympanostomy [requiring insertion of ventilating tube], general anesthesia). Classify Problem's Status Using 1st Table In the table for number of diagnoses or treatment options, you must identify the problem's status. Do so following these rules: - If the ENT has previously treated the patient for OM, CMS considers the problem established and awards two points for an established problem that is inadequately controlled, worsening or failing to progress as expected. - If this is the first time the ENT is treating the patient for OM, you should consider the diagnosis a new problem, which is worth three points. Why is there a point difference? CMS expects "that the decision-making for a known problem is less than that of a new problem," says Susan Callaway, CPC, CCS-P, an independent coding auditor and trainer in North Augusta, S.C. Calculate Reviewed Data Points Now, let's tally the amount and/or complexity of data reviewed using that table. This one is fairly simple. Because the ENT did not review any data, he receives a zero in this table. Zoom In on Table of Risk's 3 Parts Now, on to the difficult part. Let's determine the scenario's level of risk (minimal, low, moderate or high). Here's how: You select the risk level based on the single highest element identified in the table of risk's three columns (1 of 3). You do not need one element in each column. You instead assign the patient's risk using one element in the one column that represents the highest level. To get started, classify the level of these elements: - presenting problem(s) - diagnostic procedures ordered - management options selected. Look to History for Problem Details Should you classify OM with a decision for tubes as a presenting problem that is stable chronic (low), acute uncomplicated illness (low), or acute illness with systemic symptoms (moderate)? "You will get different opinions on it," says Hayes H. Wanamaker, MD, chief of otolaryngology at Crouse Hospital in Syracuse, N.Y. To get to the heart of the matter, look for more details. [...]