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Colonoscopy Medical Decision Making Risk

  1. #1
    Default Colonoscopy Medical Decision Making Risk
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    I am in the process of conducting an E&M audit for a gastroenterology practice. The majority of the patients are being seen for evaluation and subsequent scheduling of a colonoscopy. Most are due to family history and preventive reasons.

    While endoscopic procedures do carry risk i'm just not comfortable with crediting high medical decision making based solely on the procedure being ordered. The physicians feel the ordering of the procedure (colonoscopy) should be considered high MDM.

    Can anyone point me to a formal guidance document on this topic?

    Any insight is also appreciated.

    Thank You,
    Nicole Martin, CPC

  2. #2
    Default
    Quote Originally Posted by Nicole Martin CPC View Post
    I am in the process of conducting an E&M audit for a gastroenterology practice. The majority of the patients are being seen for evaluation and subsequent scheduling of a colonoscopy. Most are due to family history and preventive reasons.

    While endoscopic procedures do carry risk i'm just not comfortable with crediting high medical decision making based solely on the procedure being ordered. The physicians feel the ordering of the procedure (colonoscopy) should be considered high MDM.

    Can anyone point me to a formal guidance document on this topic?

    Any insight is also appreciated.

    Thank You,
    Nicole Martin, CPC
    I've found this helpful:
    http://www.texmed.org/Template.aspx?id=8145
    Regardless of how much history, physical examination, and/or medical decision-making related to an E&M encounter are recorded …

    •Do not consider reporting the highest two codes of any code family:
    ◦When fewer than three distinct medical conditions/complaints were evaluated and managed during the encounter, OR
    ◦No problem evaluated and managed, without appropriate intervention, conferred at least a 50/50 likelihood of worsening, disability, or death between the time of the current encounter and the next physician encounter.
    •Do not consider reporting the highest codes of any code family:
    ◦When fewer than four distinct medical conditions/complaints were evaluated and managed during the encounter, OR
    ◦No problem evaluated and managed, without appropriate intervention, conferred at least a 50/50 likelihood of worsening, disability, or death between the time of that encounter and the next physician encounter.


    Also, check appendix C for examples - it's just going to depend on the severity of the patient's condition. Hope that helps!

  3. #3
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    Default Diagnostic endoscopy
    Diagnostic endoscopy WITHOUT risk factors is listed as moderate risk
    Diagnostic endoscoy WITH IDENTIFIED risk factors is high risk.

    Please NOTE: "risk factors" means risk to the patient from the procedure (not that the patient is at risk of colon cancer). So the physician needs to clearly document the comorbidities that result in a higher risk to the patient when undergoing the procedure ... e.g. allergic to Versed, or need cardiology consult to okay for anesthesia.

    Hope that helps.

    F Tessa Bartels, CPC, CEMC

  4. #4
    Talking
    Thank you both for your insight.

    So, the general cocensus is the order of a colonoscopy in a healthy patient with either no or low risk morbidity/co-morbidity's would be expected to meet moderate risk based on the risk factors alone for the procedure while the order of the same test in a patient with high risk i.e.; current or past CAD, DVT, high risk meds such as coumadin or warafarin or other high risk acute or chronic illness would warrant high risk medical decision making.

    I was lucky enough to have two charts that were exactly the scenarios above and the patient on coumadin etc had no problem meeting high risk MDM. When scoring the two, as a matter of course, they each played out to the correct MDM levels based on the documentation. You know how our beloved docs can be though and when I present audit results I like to have iron clad rationale whenever I possibly can.

    As we know there is so much more to auditing and analysis of the coding and documenation rules as many of them have alot of grey areas. There is so much that is just not black & white. Medical decision making is definately one of those areas )

    Thanks again guys!

    Nicole

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