Part B Insider (Multispecialty) Coding Alert

Published on Thu Sep 18, 2003 PDF

Don't cheat yourself on medical decision-making for chronic patients

When a patient comes in with a minor or long-term condition related to aging, such as osteoporosis, many doctors and coders automatically see a low-level evaluation and management visit (say, a CPT 99212 ) on the way.
 
But some of those patient visits can turn out to be higher-level E/M requiring more complex medical decision-making. It starts before the patient even shows up, says coding expert Michael Miscoe with Practice Masters in Central City, Pa. "Even the dumbest problems can score high in decision-making," he says.
 
"You can predict what your decision-making potential is for a visit before it even happens," Miscoe says. For an established patient visit, in particular, if you can see a potential for reaching moderate decision-making, "I'd be tripping all over myself to get a detailed history." If the patient's history is detailed enough, it doesn't matter how complex the physical exam turns out to be.
 
The E/M coding guidelines produced by the Centers for Medicare & Medicaid Services in 1995 and updated in 1997 include three areas for deciding the level of risk (and therefore complexity of MDM) for a patient, says consultant Robin Lee with Lee-Brooks Consulting
in Chicago.
 
The first is the nature of the presenting problem or problems. Multiple conditions can raise your risk level, as can an existing condition that has worsened. If a provider is encountering a particular condition for the first time, this also raises the level of MDM, Miscoe says. If the physician orders extra diagnostic services, such as an additional workup, that adds an extra point as well.
 
The second issue is the diagnostic procedures ordered and the amount of data to be reviewed. The physician gets one point for ordering or reviewing radiographic tests or reports, one for ordering or reviewing labs, and two for performing independent visualization of an imaging study, Miscoe says. The physician can also receive two points for reviewing and summarizing old patient records, but only if she actually writes a summary.
 
The third component of MDM is the management options selected. For osteoporosis, this could include treatment options such as a diet change or over-the-counter medications. The management of osteoporosis may reach a low to moderate level, Miscoe says.
 
Once you've assigned one to four points to each of these three components, use the second-lowest of the three to determine your overall MDM level. In other words, if a physician saw a patient with a chronic condition that carries a risk of complications, morbidity or mortality for the first time, ordered some labs and reviewed some records, the three components will be moderate, high and low. You should end up with a moderate MDM level out of those three, Miscoe says.
 
It's easy to get to a moderate MDM level if this is the first time the doctor is seeing a patient with a chronic condition, says consultant Quinten Buechner with Proactive Consultants in Cumberland, Wis. Especially if the physician prescribes some medications and does a stress test or a needle biopsy, that puts the risk level at moderate.
 
Often, physicians will get used to seeing a particular complaint, such as a sore throat or otitis media, Buechner says. But if a patient with a heart transplant and other problems comes in with one of those routine complaints, it automatically has the potential to turn into something more dangerous, such as pneumonia. "Doctors who see a lot of this sort of thing automatically downcode themselves," he says.
 
Before you even look at the patient's risk level, you need to start by looking at the patient's condition and the patient's other circumstances, Buechner says.
 
Even a repeat patient with osteoporosis has the potential for a 99213, if the physician is performing the right kind of services, Buechner says. These can include prescribing meditation or telling the patient about exercises.
 
Any change in the prescription- drug regimen can help bump a patient up to a 99213, Lee agrees.