Question Scoring method of number of diagnosis or Management in MDM

Ranjitha

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Hi All,

We have a debate within coders on Scoring method of number of diagnosis or Management option in MDM I.e., Table A of MDM.
If for an established pt, in the assessment if there are 4 diagnosis documented and there is treatment given for only 2 out of 4[Physician documents treatment/plans only for 2 diagnosis], then should we count 4 diagnosis or only 2 diagnosis in Table A.
Ex: All the diagnosis are established for examiner
Assessment :
1. Headache
2. Gastroenteritis
3. Hypertension
4. Hyperlipidemia

Plan : Tramadol for Headache and Provider agrees to order EGD.
 

shereen

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Please provide the complete medical record documentation excluding PHI details for better review.
 

thomas7331

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In the practices where I've worked, we have counted the diagnoses that are either 1) documented as being evaluated/managed during the encounter, or 2) documented as affecting the provider's management and decision-making for the patient at the encounter. If the diagnosis is simply listed as an existing problem, with no mention as to the status of the condition, its treatment plan or any other comment as to how it is relevant to the encounter, then we could not count it.
 

Partha45

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Hi All,

We have a debate within coders on Scoring method of number of diagnosis or Management option in MDM I.e., Table A of MDM.
If for an established pt, in the assessment if there are 4 diagnosis documented and there is treatment given for only 2 out of 4[Physician documents treatment/plans only for 2 diagnosis], then should we count 4 diagnosis or only 2 diagnosis in Table A.
Ex: All the diagnosis are established for examiner
Assessment :
1. Headache
2. Gastroenteritis
3. Hypertension
4. Hyperlipidemia

Plan : Tramadol for Headache and Provider agrees to order EGD.
The first two diagnosis are examined today, Tramadol prescribed for headache and EGD ordered for Gastroenteritis and all other two conditions are chronic it should be considered as stable. So still you should count. Hope Headache and Gastroenteritis are new problem, if so you can count 4+4 and 2 points are last diagnosis.
 

Ranjitha

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Thank you for responses. Much appreciated but there are 2 kind of responses. Confused!!!!On whom decision should I rely on. Do we have any document that substantiate your answers.

Waiting for responses
 

Ranjitha

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E/M score sheet does not define whether you can consider all diagnosis just because its given under assessment nor it does not state to consider only if management option available for any particular diagnosis this to be considered. Only it states number of diagnosis or management option.

As I mentioned in my question "All the diagnosis are established for examiner". So as per table should I consider 2 points or should I consider 4 points. Based on this my final E/M level gets changed. That's my concern
 

kdlberg

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Upcoding is when the documentation doesn't support what is being billed, which typically related to the CPT codes. Coding diagnoses which aren't supported by the record would be just plain old fraud.

Medical decision making takes into account all acute conditions being treated AND chronic conditions that affect treatment.A diabetic on insulin, for instance, you have to watch what you prescribe so it doesn't crash their sugars or interfere with intestinal absorption.

Is it documented that the headache and gastro are new problems? The headache would be three points (new problem, no f/u) and the gastro is 4 points (new problem, follow-up--the EGD.) So already, you've maxed out the category.

If none of the problems are indicated as new or established, or the established problems have no status, they are treated as established stable diagnoses--one point each. So you'd still have 4 points and max out the category.
 

thomas7331

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What it comes down to is that you are not going to find guidelines to address every single situation that you will encounter in an E&M visit, and even the 'points' system has it limitations (all the more so now that payers are invoking 'medical necessity' to override levels chosen based on points). The audit point system is just a tool, it is not a law or regulation that governs coding. There are a lot of judgment calls that have to be in in the E&M coding and auditing process - there is no escaping this fact.

All practices ultimately need to make their own decisions at to how to deal with these situations. As I mentioned above, the practices where I've worked did not count point for problems that were simply listed on the encounter if the provider did not indicate anywhere that he or she had addressed or considered that problem in the course of the encounter. But other practices may choose to do this differently. These choices should be made based on a careful and comprehensive review of your practice's overall documentation quality, past experience with audits, tolerance for risk, and with consideration given to your individual payers' policies and requirements. If you are not able to come to a decision on how to proceed, my recommendation would be to seek the assistance of an auditing contractor to sample and review some of your documentation and give you a professional assessment of your strengths as well as your vulnerabilities. This can be a very valuable thing to do since good auditing companies can bring with them the knowledge and experience of what they've found in many other practices and payers. You can continue asking other coders how to do things and you will continue to get lots of answers and opinions, but ultimately we all have to make our decisions and do what we think is best.
 
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Partha45

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Upcoding is when the documentation doesn't support what is being billed, which typically related to the CPT codes. Coding diagnoses which aren't supported by the record would be just plain old fraud.

Medical decision making takes into account all acute conditions being treated AND chronic conditions that affect treatment.A diabetic on insulin, for instance, you have to watch what you prescribe so it doesn't crash their sugars or interfere with intestinal absorption.

Is it documented that the headache and gastro are new problems? The headache would be three points (new problem, no f/u) and the gastro is 4 points (new problem, follow-up--the EGD.) So already, you've maxed out the category.

If none of the problems are indicated as new or established, or the established problems have no status, they are treated as established stable diagnoses--one point each. So you'd still have 4 points and max out the category.
Yes,kdlberg said correct. If established problem not treated until mentioned as resolved it should be stable, so we can count for each chronic condition. HTN & HLD as chronic condition.
 

Pathos

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What it comes down to is that you are not going to find guidelines to address every single situation that you will encounter in an E&M visit, and even the 'points' system has it limitations (all the more so now that payers are invoking 'medical necessity' to override levels chosen based on points). The audit point system is just a tool, it is not a law or regulation that governs coding. There are a lot of judgment calls that have to be in in the E&M coding and auditing process - there is no escaping this fact.

All practices ultimately need to make their own decisions at to how to deal with these situations. As I mentioned above, the practices where I've worked did not count point for problems that were simply listed on the encounter if the provider did not indicate anywhere that he or she had addressed or considered that problem in the course of the encounter. But other practices may choose to do this differently. These choices should be made based on a careful and comprehensive review of your practice's overall documentation quality, past experience with audits, tolerance for risk, and with consideration given to your individual payers' policies and requirements. If you are not able to come to a decision on how to proceed, my recommendation would be to seek the assistance of an auditing contractor to sample and review some of your documentation and give you a professional assessment of your strengths as well as your vulnerabilities. This can be a very valuable thing to do since good auditing companies can bring with them the knowledge and experience of what they've found in many other practices and payers. You can continue asking other coders how to do things and you will continue to get lots of answers and opinions, but ultimately we all have to make our decisions and do what we think is best.
I agree with Thomas. Having worked both sides of the claim (provider and health plan sides) I see where each party is coming from. I understand the allure of having a point system, as this tends to stream line the auditing process a great deal. But this system is flawed. It can be so easy to bump almost any visit up to a 99214 with just a few specific macros, which then would not necessarily reflect true medical necessity. My local MAC (Noridian) explains that they recognize that some providers like to use this point system, but at the end of the day the foundation of any code boils down to medical necessity. This is not easily quantified. For example, did this Otitis Media require antibiotics/or any Rx, new problem to the provider, with a Detailed History? If you follow the points system, this could fairly easily appear to qualify for a 99214 visit, but is it truly a visit on par with other visits that manage several chronic conditions with complicated interactions (yet not severe enough to "qualify" for a High MDM)? Here is my Noridian reference.

I think CMS is trying to move away from the Marshfield Clinic audit tool (the point system) through their new Patients over Paperwork initiative. In a couple years (2021), they are doing a significant overhaul of the E/M codes and what they will accept in terms of claims and documentation requirements. If you haven't already read up on this major change, I highly recommend you read up on it, like yesterday! This is no longer a proposed rule (although there might be a few fine adjustments still), but will happen. There have already been some changes for 2019 in terms of the HPI and ancillary staff.

CMS statement
 

kdlberg

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The visit level should also match the nature of the presenting problem. Level 4, per the CTP book, addresses "problems of moderate severity." Would we call uncomplicated otitis media a moderately severe problem? I wouldn't

CMS is definitely pushing towards looking at just the MDM, or coding based on time. They're operating under the assumption that, as the population continues to age, medicine will evolve into a system based on chronic care management. I'll keep counting points until they tell me to stop. :)
 
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