Wiki Dx on Table of risk

[wynonna]

Under Table of Risk, HIGH risk, are examples such as: multiple trauma, acute MI, pulmonary embolus, severe respiratory disease, severe rheumatoid arthritis, acute renal failure, peritonitis, seizure, TIA weakness, sensory loss. (they are under Present Problem, High Risk, on bottom left of Table of Risk.) Sepsis is a common cause of death and is a systemic inflammatory response to infection. Urosepsis may have begun as a urinary tract infection and spread systemically. Normally when we are the first provider to see a patient after such a serious event that landed our patient in the hospital, I view it as high risk, and verify it as a 99215 assuming Exam is comprehensive, and note has also scored High risk under Number of Diagnoses/Management Options.
Thank you for your input

 

[thomas7331]

I normally do not assign a level of risk just off of a diagnosis, but rather look for the level of risk that the provider has documented as relates to the patient's current condition and the decision-making that they are performing at that encounter. The reference from the CMS guidelines that I often cite for coders states is as follows:

Because the determination of risk is complex and not readily quantifiable, the table includes common clinical examples rather than absolute measures of risk. The assessment of risk of the presenting problem(s) is based on the risk related to the disease process anticipated between the present encounter and the next one. The assessment of risk of selecting diagnostic procedures and management options is based on the risk during and immediately following any procedures or treatment. The highest level of risk in any one category (presenting problem(s), diagnostic procedure(s), or management options) determines the overall risk.

This suggests two things to me - first, that risk is not something that kind be easily assigned according to a formula, and requires a clinical judgment. As such, this an assessment that is up to the provider to make and should be reflected in their documentation. And second, that risk as related to MDM, is not just about the risk of a diagnosis, but rather is about how the risk increases the difficulty of the provider's work based on how it impacts the different treatment options that the provider has to consider and manage in the course of the encounter. Rather than just assigning a risk based on a diagnosis, a coder or auditor should consider the provider's assessment of the patient, the types of treatments or tests the provider is considering, what possible outcomes or negative side effects the provider has to consider as part of their planning, the extent of the follow-up care of monitoring that will be needed, whether the provider is actively managing a condition or if it is just a co-morbidity that has to be taken into consideration, etc.

Regarding your specific scenario, while you're correct that sepsis can be life-threatening, if the patient has been discharged and the condition has presumably been resolved, then the risk "related to the disease process anticipated between the present encounter and the next one" may not be that high if the patient has responded well to treatment. On the other hand, the status of the patient could also be quite complex or high risk for re-admission and may indeed support a high level of MDM. There's really no way to know which, though, without looking at each individual note. So it is important to consider each encounter note on its own merits and choose a code accordingly, and not rely on a formula for selecting a level based on a general scenario. Just my thoughts.

 

[Pathos]

I normally do not assign a level of risk just off of a diagnosis, but rather look for the level of risk that the provider has documented as relates to the patient's current condition and the decision-making that they are performing at that encounter. The reference from the CMS guidelines that I often cite for coders states is as follows:

Because the determination of risk is complex and not readily quantifiable, the table includes common clinical examples rather than absolute measures of risk. The assessment of risk of the presenting problem(s) is based on the risk related to the disease process anticipated between the present encounter and the next one. The assessment of risk of selecting diagnostic procedures and management options is based on the risk during and immediately following any procedures or treatment. The highest level of risk in any one category (presenting problem(s), diagnostic procedure(s), or management options) determines the overall risk.

This suggests two things to me - first, that risk is not something that kind be easily assigned according to a formula, and requires a clinical judgment. As such, this an assessment that is up to the provider to make and should be reflected in their documentation. And second, that risk as related to MDM, is not just about the risk of a diagnosis, but rather is about how the risk increases the difficulty of the provider's work based on how it impacts the different treatment options that the provider has to consider and manage in the course of the encounter. Rather than just assigning a risk based on a diagnosis, a coder or auditor should consider the provider's assessment of the patient, the types of treatments or tests the provider is considering, what possible outcomes or negative side effects the provider has to consider as part of their planning, whether the provider is actively managing a condition or if it is just a co-morbidity that has to be taken into consideration, etc.

Regarding your specific scenario, while you're correct that sepsis can be life-threatening, if the patient has been discharged and the condition has presumably been resolved, then the risk "related to the disease process anticipated between the present encounter and the next one" may not be that high. At the same time, the status of the patient could also be quite complex and may indeed support a high level of MDM. It is really important to consider each encounter note on its own merits and choose a code accordingly, and not rely on a formula for selecting a level based on a general scenario. Just my thoughts.

I agree with Thomas, when you consider the Overall Risk in the Medical Decision Making section, you need to check the provider's documentation. What is the provider doing with the issue(s) the patient is having? The Assessment/Plan portion should show a snapshot of the patient's current condition.

Let's look at the High Risk section of "Presenting Problems" - "Acute or chronic illnesses or injury that pose a threat to life or bodily function". I agree that urosepsis could likely lead to that scenario, but as Thomas is saying; the patient was just discharged from the hospital and most likely should be stabilized. Their condition should no longer be life threatening or threat to bodily function, unless documentation directly suggests otherwise (which begs a whole other slew of questions). It is more likely that the Presenting Problem is either "stable" which would probably fit in Low or Moderate Risk; again depending on documentation.

To put this into another perspective, the hospitalist who was treating this patient could likely claim a "High Risk" when first managing the patient. However, again this would depend on medical necessity and patient documentation.

Hope this is helpful.

 

[wynonna]

Thank you so much. Very helpful

 

[natashalage]

Thank you.

I also would like to say a big Thank you to Thomas and Pathos for your detailed explanation of MDM and other topics! I am a new pro fee coder and trying to learn as much as I can. I read threads of this Forum and keep expanding my knowledge and don't want to miss any topic; it's fun, interesting and very helpful. You are awesome. Thank you for your thorough responses and your Time. We do learn from you.

 

[carolhodge]

I totally agree with the above post. I too follow these forums and have learned so much and appreciate the time and effort the responders puts into their answers.

Carol Hodge, CPC, CDEO, CCC, CEMC