Part B Insider (Multispecialty) Coding Alert

When scoring, it's important to know that not all of these classes have a score of one point. The review and summary of old records and the independent review of image both have 2 points assigned to them.

Tip: You receive a point when you order a test, and you receive a point again when you review the test results at the next visit, notes Barbara J. Cobuzzi, CPC, CPC-H, CHBME, president of Phoenix Healthcare Solutions in Brick, NJ. This "double dipping" only works if you order and review in separate sessions. You may not receive double points if your order and review in the same session, she cautions.

Beware: Never assign points for each lab test or each x-ray. All tests within a class are considered as a group. Ordering and interpreting 5 x-rays will still only earn you 1 point for ordering and 1 point for reviewing the x-rays at the next visit.

Get Paid For Reading A Film: Physicians often want to know how to bill for interpreting the x-ray films their patients bring to the office. You can't bill reading as the professional component, says Cobuzzi, as the radiologist has already billed that. But what you can do is report the film review as an "independent visualization" and collect 2 points for the MDM data section, she explains.

Example: A patient presents with a swollen, bruised, and lacerated finger that he caught in a closing truck door three days earlier. Suspecting the finger is both broken and infected, the physician orders x-rays and a labs to check to see if there is indeed an infection. He reviews the results that day and determines that while not broken, the finger is infected. Score: Two points, one for ordering and interpreting the labs, and one for ordering and interpreting the finger x-ray. You should therefore assign a data complexity level of "low."

Calculate The Risk

Level of risk, the third component of MDM, can be the most difficult part to determine because it is the most complicated. Unlike with the other two components, you determine a patient's level of risk by selecting the highest score (minimal, low, moderate, or high) of the component's three categories: presenting problem, diagnostic procedures ordered, and management options. CMS's 1995 guidelines for MDM have a "Table of Risk" with examples of each of the three categories (see www.cms.hhs.gov/medlearn/1995dg.pdf)

Example: A female patient suffering from hypertension and diabetes comes in complaining of frequent hypoglycemic attacks. The physician draws blood for a full workup and changes her insulin protocol.

Assess the Risk: According to the Table of Risk, a patient with one or more chronic illnesses with mild exacerbation falls under "moderate" in the "presenting problems" category. You should assign "minimal" to the diagnostic procedure because the physician only orders and reviews the bloodwork.

Prescription drug management, such as writing a prescription, is considered moderate risk in the table, notes Laureen Jandroep, OTR, CPC, CCS-P, CPC-H, CCS, senior instructor and director at the CRN Institute.  Since the physician changes the patient's insulin protocol in this case, the management options category receives a "moderate" level of risk.

Final Score: You should select the highest of the three to determine level of risk, says Jandroep. In this case, the highest level of risk is "moderate" because of the prescription drug management and the patient's presenting problems.

See The Big Picture

Once you understand how to score the three components, you can easily put them all together and determine the physician's MDM. Study this example and see if you can determine the MDM by assessing all three components.

Example: A patient comes in with migraine headaches and the physician writes them a prescription for Midrin.

Final  MDM Score: You should select "straightforward."

Rationale: There is only one diagnosis, the migraine, (minimal), there is no data to review (minimal), and the level of risk is "moderate" because of the prescription drug management. However, two of the three levels of MDM must be met or exceeded. With two scores of "minimal" you must assign an MDM level of straightforward.