Wiki Determining MDM- HELP!!!!!

[mjsanford77]

I am looking for some guidance, I seem to be getting conflicting info and I just can't seem to wrap my head around determining the level of MDM....Here's what I have- provider is pain management and treats patient's consistently for the same issues..

In my example this is what I have - Hx is Detailed, Ex is Detailed...clear and cut...But the MDM I think I am overthinking and I need some assistance or tutoring...In the assessment I usually have 4 dx codes, sometimes more...For this example I have dx codes listed G89.4 (Chronic Pain Syndrome), M54.12, (Radiculopathy cervical region) M25.511 (rt shoulder pain), and M25.512 (lt shoulder pain)----Provider states Reviewed UDT, MRI, and Refilled Rx Opioids

Do I count- 4 points dx under the dx/management options because he has 4 dx listed (High).......2 points for Data (UDT and MRI review) LOW, and under Risk- MODERATE for Rx refill and he states in the Risk section 1 chronic condition with mild exac- this leads me to believe it's the Chronic Pain syndrome since he is managing the patients pain

I am thinking Moderate Overall----High on dx/managment, Low on Data, and Moderate on Risk....Am I doing this right.....the dx are all established codes...no indication of worsening,

 

[Pathos]

The Medical Decision Making (MDM) is notoriously the most subjective and perhaps also most challenging part of any E/M coding, however guidelines and tools have been developed to make this part of the E/M more palatable.

Let's break the MDM down first:

CMS states that:
"Medical decision making refers to the complexity of establishing a diagnosis and/or selecting a management option as measured by:
-the number of possible diagnoses and/or the number of management options that must be considered;
-the amount and/or complexity of medical records, diagnostic tests, and/or other information that must be obtained, reviewed and analyzed; and
-the risk of significant complications, morbidity and/or mortality, as well as comorbidities, associated with the patient's presenting problem(s), the diagnostic procedure(s) and/or the possible management options."

Although CMS has not developed a point system like the Marshfield Clinic tool (commonly adopted by other entities including AAPC), the real kicker is medical necessity. Since you cannot quantify medical necessity, let's take on MDM using the tool AAPC recommends:

Diagnosis and/or Management Options: 4 (4 established stable problems, assuming the provider addresses each problem individually, and provides some form of medical management, and doesn't merely just list them)

Amount and Complexity of Data: 2 (review lab [UDT], review radiology [MRI])

Overall Risk:
-You mentioned that the provider hinted at a "Chronic condition with mild exacerbation", but at another time mentioned that all conditions were established and no indications of worsening.
-However, if at least two of the chronic conditions are stable, then you should get a Moderate under Presenting Problems.
-Also, you mentioned "Rx refill" which would generally grant you a Moderate Medical Management. Some payers require providers to change the prescription before you get Moderate. There is some discussion whether this is appropriate or not, however the feedback I am getting is the same clinical thought process and risk go into any Rx management.


That said, CMS also says: "If it wasn't documented, then it didn't happen", meaning if the provider didn't enter it into the EHR, then he/she cannot get credit for the work. Also, medical necessity is ALWAYS the overarching criterion no matter what the other E/M components show.

Hope this helps.

 

[amla12]

Overall Risk:
-You mentioned that the provider hinted at a "Chronic condition with mild exacerbation", but at another time mentioned that all conditions were established and no indications of worsening.
[/QUOTE]

Those two remarks do seem to conflict. If there is exacerbation (mild or not) that is the same as worsening, no?

 

[Pathos]

Yes, I saw this ambiguity and didn't use this worsening problem towards Risk or Dx/Mx options. Instead I went with the more conservative option and used established stable problems towards Dx/Mx.