Wiki What element level of MDM would a specialist referral fall under 2021 E/M Guidelines?

SLindloff

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Our PCP providers would like to consider a referral to a specialist as a LOW RISK under column 3 of the 2021 E/M table for Risk of Complications and/or Morbidity or Mortality of Patient Management. In comparison to Box A. of the 2020 & earlier E/M table and guidelines, whether a condition was established and worsening (2 pts.), or was new and required additional work up (4 pts.), the diagnosis itself would be considered at minimum of low complexity. The guidance from this section originally indicated: "Need to seek advice from others is another indicator of complexity of diagnostic or management problems"
So my question is this: If the PCP provider documents the conditions as worsening or new requiring additional work-up outside the scope of said practice, and documents a referral to a specialist for additional treatment, according to the 2021 E/M Table, would you consider this a Low level of MDM based on column 1 (# and complexity of problems addressed) and column 3 (risk of complication and/or morbidity or mortality of patient management)?

Appreciate the feedback and any links available indicating where referrals fall under the 2021 E/M Guidelines.

Thanks,
Shannon Lindloff, CPC, CRC
 
I have this exact same question, Shannon. I haven't been able to find the best "placement" for a referral on the MDM table.
Today in the new Healthcare Business Monthly for Nov 2021 I read that a referral does not count as data, but does count as care coordination in response to someone asking if referrals count towards care coordination. They specially noted that it doesn't count as data but did not say anything about the other 2 elements.

We currently count referrals as Low risk, with the possibility of being counted as a moderate risk should urgency/increased risk play a factor.
Often times I find when the providers are making a referral outside of their scope of practice for treatment, the risk of the patient's condition worsening/continuing becomes a factor.

would love other's input on this as well!!!
Nathalie
 
Our PCP providers would like to consider a referral to a specialist as a LOW RISK under column 3 of the 2021 E/M table for Risk of Complications and/or Morbidity or Mortality of Patient Management. In comparison to Box A. of the 2020 & earlier E/M table and guidelines, whether a condition was established and worsening (2 pts.), or was new and required additional work up (4 pts.), the diagnosis itself would be considered at minimum of low complexity. The guidance from this section originally indicated: "Need to seek advice from others is another indicator of complexity of diagnostic or management problems"
So my question is this: If the PCP provider documents the conditions as worsening or new requiring additional work-up outside the scope of said practice, and documents a referral to a specialist for additional treatment, according to the 2021 E/M Table, would you consider this a Low level of MDM based on column 1 (# and complexity of problems addressed) and column 3 (risk of complication and/or morbidity or mortality of patient management)?

Appreciate the feedback and any links available indicating where referrals fall under the 2021 E/M Guidelines.

Thanks,
Shannon Lindloff, CPC, CRC
Hi Shannon. Did you ever get a definitive answer on this?
 
Hi Shannon. Did you ever get a definitive answer on this?
This excerpt below is taken from : https://www.ama-assn.org/system/files/2019-06/cpt-office-prolonged-svs-code-changes.pdf

'For the purposes of MDM, level of risk is based upon consequences of the problem(s) addressed at the encounter when appropriately treated. Risk also includes MDM related to the need to initiate or forego further testing, treatment, and/or hospitalization. The risk of patient management criteria applies to the patient management decisions made by the reporting physician or other qualified health care professional as part of the reported encounter.'


Hope this helps .
 
I still have the same question. The documents linked are very helpful, but I don't feel they answer our question.
My instincts are, referrals to specialists should be considered low risk, because physical therapy is on the MDM table in the low risk column. If referring to PT/OT counts, shouldn't a referral to anyone else count there as well?
Hoping someone knows the answer...
 
I still have the same question. The documents linked are very helpful, but I don't feel they answer our question.
My instincts are, referrals to specialists should be considered low risk, because physical therapy is on the MDM table in the low risk column. If referring to PT/OT counts, shouldn't a referral to anyone else count there as well?
Hoping someone knows the answer...
I have not seen any official guidance on this issue. In my opinion, it a gray area and dependent on the rest of the context. Did the patient say "my big toe sometimes hurts" and your doc simply said "Go see a podiatrist." Or did they have a discussion about timing, severity, ordered an xray for it?
I think the reason PT/OT is there meaning the doctor writes an order for "PT for left ankle pain following fracture 3x per week for 6 weeks."
My unofficial rule is if my doc didn't really evaluate the problem and just said "go see _______", that's minimal. If my doc evaluated the problem and thinks the patient needs a specialist to discuss surgical options, that's at least low.
 
I have yet to read the links, that is my next step. However, I want to enter my scenario for additional thoughts. Male patient in his 20s has repeated pressure injury of skin to right foot (states pressure ulcers off and on over the years) and was referred to Wound Care in July 2022 but did not go (referral is still active) and then referred to Wound Care again, as well as Podiatry in October 2022 when he was seen again for the same issue, once again on the right foot. Our determination is due to the nature of the problem (chronic pressure ulcers on foot) and the referrals for both Wound Care and to a specialist (Podiatry) the Risk could be considered as Moderate per the MDM table. I see C. Speroni commented above "that's at least low" therefore, please share thoughts as to considering this for Moderate Risk. Thank you.
 
per Noridian ACT Q & A March 10, 2022:
Noridian ACT Q & A March 10,2022

Q12. Do providers receive credit in MDM for referring a patient to another provider?
A12. Yes, this would meet patient management for treatment when it is necessary to refer to another provider.

ALSO, per Noridian:
Noridian E/M office or other outpatient services top provider Q with A

"Q6. The patient's problem today results in a referral to another specialty. When using MDM to choose the level of service, how would we count this?
A6. You are addressing or managing a problem when evaluating or treating during the encounter. A notation in the medical record indicating another practitioner is treating without additional assessment or care coordination does not qualify for MDM. Referral without evaluation (by history, exam, or diagnostic study(ies) or consideration of treatment does not qualify for MDM as nothing is being addressed or managed. If you address the problem, utilize the level of the problem, amount and complexity of data, and risk to patient from the referral to assign your category of MDM."
 
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