Wiki E/M MDM Orthopaedic question

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olivesangel

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I'm not sure if it's just me, but I have a very difficult time trying to figure out the Level of MDM for a lot of orthopaedic issues. Is there a "place", reference? guide? to go to find these out? My practice is orthopaedics from head to toe and every little bit in between. If I have to go to a provider and say that spondylosis isn't "this" level or internal derangement, DeQuervain's, onychomycosis, or PVD, necrosis, etc. How can I be sure? I know this may sound rookie-ish, but I am struggling. Please and thank you.
 
To me, there is no single problem that is always a certain level.
For example, a splinter might typically be straightforward (self-limited or minor). But this specific patient had a splinter for 3 weeks and is now infected and filled with pus.
It all depends on the documentation of the particular patient's case at the time of treatment. You mention the example of spondylosis.
Patient A with spondylosis may be experiencing some mild pain, otherwise healthy. Stating that problem is more than low seems like a stretch.
Patient B with spondylosis may be experiencing significant pain, numbness and bladder incontinence. Calling that problem moderate seems appropriate. Possibly even high if there is severe exacerbation.

Even a patient with cancer could have problem level of low, moderate or high. And it will fluctuate during the course of illness and treatment depending on response to treatment and side effects.
To me, you have to level each particular service based on the documentation of status of the problem at the time of care, not simply by what the problem is.
Don't forget that number and complexity of problems addressed is only 1 of 3 elements for overall MDM. You need not just the problem level, but also data level and risk level.

I recommend going back to the basics of the AMA guidelines. When the new guidelines came out in 2021, I must have referenced that document literally hundreds of times. Read and re-read and re-read the definitions. If your providers are consistently calling a problem higher than you think it is, it is also possible they are not DOCUMENTING well enough.
 
Don't look at it from the perspective of what the presenting problem is. Look at it from the documentation. Do some of them code by time instead of MDM?
Do you have a more senior coder or manager/supervisor in your practice that has experience with E/M specifically for your practice that you can learn from?
E/M seems to be the most confusing and most difficult piece to learn for all, in my experience. One way I got better at it years ago, specifically in orthopedics was having to teach others how to do it. I do think it is much easier now instead of back when we had the old guidelines.
What, specifically do you struggle with on it?
Years ago a coding-partner hand/wrist surgeon I worked for had a really good way of looking at it when we would try to help new providers learn E/M. He said look at it this way - what's wrong (why are they here?), how bad is it (severity?), what are you doing about it (plan/treatment?), and how soon did you tell them to come back (surgery tomorrow, go to ED, admit to IP, come back as needed, etc?). That can help.

I would suggest using AAOS resources, KZA, and also try using your local MAC's E/M auditing tools.
At one time AAOS has two free webinars about E/M. You can join the site for free. Some content is only for members, but I have used a lot of their coding resources. If your providers are members, they can get access to more and sometimes share with you.

MAC example of auditing tool: https://www.novitas-solutions.com/webcenter/portal/MedicareJH/EMScoreSheet

AAOS: https://www.aaos.org/quality/coding-and-reimbursement/
For residents but applicable concepts: https://www.aaos.org/quality/reside...-for-residents/evaluation--management-coding/

KZA: https://educate.kzanow.com/products/aaos-members-on-demand-2022-em-in-the-office-office-modifiers

Look at AAPC Webinars and resources: https://www.aapc.com/blog/51038-gain-solid-footing-for-orthopedic-e-m-coding/

Of all the topics of coding, E/M is the easiest one to find help and resources for.
 
csperoni said:
To me, there is no single problem that is always a certain level.
For example, a splinter might typically be straightforward (self-limited or minor). But this specific patient had a splinter for 3 weeks and is now infected and filled with pus.
It all depends on the documentation of the particular patient's case at the time of treatment. You mention the example of spondylosis.
Patient A with spondylosis may be experiencing some mild pain, otherwise healthy. Stating that problem is more than low seems like a stretch.
Patient B with spondylosis may be experiencing significant pain, numbness and bladder incontinence. Calling that problem moderate seems appropriate. Possibly even high if there is severe exacerbation.

Even a patient with cancer could have problem level of low, moderate or high. And it will fluctuate during the course of illness and treatment depending on response to treatment and side effects.
To me, you have to level each particular service based on the documentation of status of the problem at the time of care, not simply by what the problem is.
Don't forget that number and complexity of problems addressed is only 1 of 3 elements for overall MDM. You need not just the problem level, but also data level and risk level.

I recommend going back to the basics of the AMA guidelines. When the new guidelines came out in 2021, I must have referenced that document literally hundreds of times. Read and re-read and re-read the definitions. If your providers are consistently calling a problem higher than you think it is, it is also possible they are not DOCUMENTING well enough.
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I agree and recommend always looks at E/M visits on a case by case basis no matter the specialty.

I work with a pediatric ortho group and often find when working with them that because they are so high volume that they are missing documenting things that they do or not being specific enough. Also usually secondary to use of scribes who are relying on a template and not well versed in capturing those small details that can make a difference. To help with this, we are also working with the scribes to better understand the importance of capturing everything in the visit.
 
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