Wiki Liability

[Sarah Ann]

(MDM encounters)
Has anyone encountered clinicians unwilling to state the overall level of risk(as it is defined in Cpt) due to liability?

 

[jkyles]

Sorry, are they saying they don't want risk to be a factor in MDM-based coding?

 

[Sarah Ann]

Sorry, are they saying they don't want risk to be a factor in MDM-based coding?

I'm being told by management they(clinicians) don't want to document the risk, because there's a liability in doing that. Many of the clinicians document a differential diagnosis, there could be liability in doing that as well, so why is this more of a liability? It's something coders have to "construct" from the MDM like treatment options.
AMA Article:

Q
Please elaborate on what constitutes Prescription Drug Management is it enough to simply
review a medication list, does there need to be management of the condition, etc.? Also, does
a provider stating “there is a moderate risk for an over the counter medication” enough to
justify a moderate level of risk re: patient management?


A
There is no “blanket” guidance for services to represent specific levels of risk. The physician is
responsible for assessing (and documenting) the level of risk of the services to be performed
including medicine management, (prescription or OTC), based on a specific patient’s risk factors
and the risks typically seen with the drug. For example, an NSAID in a person with kidney
disease or on anticoagulant is of greater concern that most prescription drugs. Simply
reviewing a medication list does NOT constitute prescription drug management.

 

[jkyles]

Right, the AMA has made very clear that the provider determines risk (and complexity of the problem) under the new guidelines.

This is a discussion for a health care attorney, but my two bits is this sounds like the common confusion about who is responsible for claims.

It is the billing provider. Not the coder, or the EHR or the person the provider met at a conference who told them something. So if you code a level 3 office visit for Dr. S based on documentation that supports moderate complexity of care and moderate risk. Dr. S has in effect documented that Dr. S believes the patient has a moderate risk of complications and/or morbidity or mortality from their patient management decision. In the case of a med-mal suit, Dr. S can't say "I never wrote the words 'moderate risk,' that was the coder."

That's why I asked if they want you to leave risk out of your coding.

 

[thomas7331]

It sounds to me like your providers don't want to specify the level of risk that coders need within the text of the patient's medical record, and I can sort of understand this. They probably imagine that stating this could be used against them in a malpractice case if a patient had a negative outcome after they had stated that a risk was low, for example. This is understandable as putting a patient's risk in these terms could be misunderstood by a non-clinician. The levels of risk (i.e. straightforward, low, moderate, high) are terms for determining code levels that aren't quantifiable and so not really defined in medical usage, so I can see why the providers would resist including these in the documentation.

The AMA article is ambiguous, I think, in that it says that provider must document the level of risk. I take this to mean that the providers must document the factors involved in the patient's condition and treatment plan that affect the risk and would therefore be used to assign a risk level for the encounter. I don't understand this to mean that providers are must document the words 'low', 'moderate', etc., in the patient's record for coding purposes. I would not push them to do this if they are uncomfortable with it. The medical record belongs to the provider and the patient, and no one else, so they have the final say on this, and as coders we need to just do the best we can with this.

 

[Sarah Ann]

Pt comes in with an acute uncomp. illness they do no tests- they tell the patient to take tylenol. With the new 2023 grid this is a 1. 99212 because there's nothing under OTC in CPT.

2. same scenario, but they give the pt an rx for cyclobenzaprine- but this one is a 99213 using the new 2023 E/M table, which has been updated.- rx management.
I know it's based on 2 out of 3. The table is confusing, I know if they document a condition could be affected by an OTC that could bring it up to Rx level. 99213.