Wiki E/M coding General SX looking for Help

[JDuhaime]

Looking to talk to someone for some help to determining level of E/M for H&Ps general SX. The provider uses a level 5 a lot and I feel that they are 4s at best. I am looking for a little guidance to help me feel more confident in my decision as I am new to gen sx and still grasping E/M coding. I question my decision constantly.

 

[csperoni]

To me, the AMA 2021 outpatient guidelines are the best official resource to use. Carefully read all the definitions. Then re-read it all. Then read it again. The first 17 or so pages (up to Prolonged Services) I must have read 100 times over the past year.
For patients being seen with major surgery as a recommendation, you are likely at level 5 for high risk - decision regarding elective major surgery with identified patient or procedure risk factors. In order to get an overall level 5, that means you must also have level 5 for problems or data.
Problem - level 5 is 1 or more chronic illness with severe exacerbation, progression or side effects of treatment OR 1 acute or chronic illness or injury that poses a threat to life or bodily function.
Data - level 5. Most likely, you are meeting Category 1 (3 or more of review test, order test, review prior external note, independent historian). We meet it just ordering PST labwork. You then also have to meet either Category 2 - independent interpretation of tests or Category 3 - discussion with external qualified health professional.

So, while it's certainly possible for a surgery patient to be a level 5, it could vary from patient to patient depending on the specific documentation and specific circumstances.

Remember that in order to credit the physician for the MDM being made, their documentation needs to be clear. If the physician thinks it's level 5, but the coder thinks it's level 4, usually there's 1 of 2 things occuring. 1) The physician is considering everything, but not everything is on the note. 2) Someone (could be either the physician or coder) is not well versed in the 2021 changes.

 

[JDuhaime]

To me, the AMA 2021 outpatient guidelines are the best official resource to use. Carefully read all the definitions. Then re-read it all. Then read it again. The first 17 or so pages (up to Prolonged Services) I must have read 100 times over the past year.
For patients being seen with major surgery as a recommendation, you are likely at level 5 for high risk - decision regarding elective major surgery with identified patient or procedure risk factors. In order to get an overall level 5, that means you must also have level 5 for problems or data.
Problem - level 5 is 1 or more chronic illness with severe exacerbation, progression or side effects of treatment OR 1 acute or chronic illness or injury that poses a threat to life or bodily function.
Data - level 5. Most likely, you are meeting Category 1 (3 or more of review test, order test, review prior external note, independent historian). We meet it just ordering PST labwork. You then also have to meet either Category 2 - independent interpretation of tests or Category 3 - discussion with external qualified health professional.

So, while it's certainly possible for a surgery patient to be a level 5, it could vary from patient to patient depending on the specific documentation and specific circumstances.

Remember that in order to credit the physician for the MDM being made, their documentation needs to be clear. If the physician thinks it's level 5, but the coder thinks it's level 4, usually there's 1 of 2 things occuring. 1) The physician is considering everything, but not everything is on the note. 2) Someone (could be either the physician or coder) is not well versed in the 2021 changes.

This is helpful. He does have ones worthy of a 5. Majority of them are decision for sx but he does not identify risk factors or what makes them high risk. Which I feel is a level 4.

 

[csperoni]

Correct - "decision regarding major surgery without identified patient or procedure risk factors" is moderate risk (level 4 for risk). If a minor surgery without identified risk factors, consider that low risk (level 3 for risk).
I would note that may be a good opportunity to educate your provider. I've never worked with a surgeon that didn't discuss the risks with the patient. I have worked with surgeons that did a less than stellar job of documenting that in the record.
PS - especially if you're new at this, make sure in any education to your providers that you are not questioning their medical judgement, decision making, etc. You are simply trying to ensure they get credit for any and all work they did, but that might be unclear in the documentation.