Part B Insider (Multispecialty) Coding Alert

Published on Mon Jun 16, 2014 PDF

You can get extra points under ‘management options’ for new problems…if you know what they are.

When it comes to choosing the overall level of service for an evaluation and management encounter, such as an office visit, most coders will tell you that determining the medical decision making (MDM) complexity is the most complicated and difficult piece of the puzzle. Not only is the MDM a head-scratcher, but even the individual elements under it can be tough to navigate.  

Such is the case when addressing a new problem, which can snag you more points than an established one. But many practices struggle to define what makes a new problem “new.” Fortunately, one MAC stepped in to clarify this issue last week.

Background: To determine the level of MDM, you should assign points to each of the three MDM components that your doctor performs. The number of points in each category determines the final MDM level. There are three elements that contribute to the complexity of the medical decision making: diagnoses/management options, complexity of data reviewed/ordered, and the table of risk. You must have two out of the three MDM components score at a particular level in order to assign that level of MDM. 

Understand Each Level of Diagnosis 

Start your MDM level assessment by tackling the first category: number of diagnoses. For this category, ask yourself what’s wrong with the patient, and are the diagnoses new? For each diagnosis, you will assign a point and score the diagnosis level as follows: 

• Self-limited/minor problem -- 1 point each, with a max of 2 points
• Established problem, improving/stable -- 1 point each
• Established, worsening -- 2 points each
• New problem, no planned additional workup -- 3 points each, max of 3 points
• New problem, additional workup -- 4 points each

So what exactly constitutes a “new” problem? “In most instances, a new problem is one that is new to the provider and being addressed at that visit,” said Part B MAC Palmetto GBA on its website in a June 10 E/M Tip. “There are two exceptions to this general rule: 

The initial visit of an established beneficiary in a single specialty group practice setting with a new provider 

A visit by an 'on call' or covering provider. In these instances, the established problems are treated as if the beneficiary was seen by the unavailable provider.”

Example: An established diabetic patient with hypertension comes in complaining of flank pain. The physician evaluates the patient’s pain and orders bloodwork and a CT scan. The results indicate that the patient has a kidney stone. The doctor also renews prescriptions for the patient’s diabetes and hypertension. The physician has treated one new problem (the kidney stone) and two established (but stable) problems—the hypertension and diabetes.