Wiki MDM- Possible Management/ Testing Options

[Queizati]

Hello,

I was wondering if I could get some input regarding giving credit for possible management options and tests considered when the physician is considering these options pending patient response.

CPT Guidelines:

The risk of complications and/or morbidity or mortality of patient management decisions made at the visit, associated with the patient’s problem(s), the diagnostic procedure(s), treatment(s). This includes the possible management options selected and those considered but not selected, after shared MDM with the patient and/or family.
Risk: The probability and/or consequences of an event. The assessment of the level of risk is affected by the nature of the event under consideration

Here are some examples of what the notation looks like that I'm coming across:

1) "If the patient has not improved with the above therapies (PT, OTC meds) may consider MRI for further evaluation."

2) "If the patient's pain is without continued improvement may consider ESI/MBB/TFESI."

3) "Discussed possible management options with the patient including PT/OT, corticosteroid injections, and surgery should all other management options fail."

I'm conflicted over the fact that these are possible management options/tests, but they are not being recommended to the patient at the point in time of the visit. I would appreciate any thoughts or feedback on how you would count this if you were reviewing a note.

 

[Cwirtalla]

When my providers add this type of documentation to their notes, I do not give credit towards the MDM. I would give the credit at the visit that the order the test or use the treatment in their plan of care. However, if they recommend the service and it is noted that the patient declined, I will give them credit, unless it is for a test that must be ordered such as an MRI.

 

[csperoni]

I only consider treatment options actually considered and fully discussed with patient. Unless this is simply poor documentation, it does not seem the provider fully evaluated and discussed the potential possible future treatment options with the patient. Especially examples 1 & 2, they seem almost like notes/reminders for the clinician at this point. Example 3 - did the provider actually discuss surgery with the patient? What surgery? What risks?
There are situations where treatment options not being recommended would still be counted. Something like "Discussed with patient the typical treatment for her 5cm ovarian cyst would be a laparoscopic left ovarian cystectomy. Due to her uncontrolled DM II which could delay healing, surgery not recommended at this time. F/up with endocrinologist. Once DM II better controlled, can reconsider surgery. Repeat TV US in 6 weeks to ensure no concerning growth of cyst.". THAT is documentation of a decision regarding surgery. "Discussed possible surgery if other treatments fail" is not.

 

[Queizati]

When my providers add this type of documentation to their notes, I do not give credit towards the MDM. I would give the credit at the visit that the order the test or use the treatment in their plan of care. However, if they recommend the service and it is noted that the patient declined, I will give them credit, unless it is for a test that must be ordered such as an MRI.

I only consider treatment options actually considered and fully discussed with patient. Unless this is simply poor documentation, it does not seem the provider fully evaluated and discussed the potential possible future treatment options with the patient. Especially examples 1 & 2, they seem almost like notes/reminders for the clinician at this point. Example 3 - did the provider actually discuss surgery with the patient? What surgery? What risks?
There are situations where treatment options not being recommended would still be counted. Something like "Discussed with patient the typical treatment for her 5cm ovarian cyst would be a laparoscopic left ovarian cystectomy. Due to her uncontrolled DM II which could delay healing, surgery not recommended at this time. F/up with endocrinologist. Once DM II better controlled, can reconsider surgery. Repeat TV US in 6 weeks to ensure no concerning growth of cyst.". THAT is documentation of a decision regarding surgery. "Discussed possible surgery if other treatments fail" is not.

Thank you both for this feedback; that really is all there is to the documentation, unfortunately. For examples 1 & 2 there is no discussion documented with the patient regarding the MRI or the spinal injections so I can certainly see why it reads like a mental checklist the provider wrote down to reference. I do give credit when the provider documents they discussed a management option with the patient and the patient declined but very often only get this type of vague documentation. Oftentimes, I feel some of them throw out blanket statements such as example #3 thinking it will act as a template to get their visits to a higher level without doing any of the documentation work.