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Medical Decision Making - risk component

  1. #11
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    Medical Coding Books
    In my opinion, self-limited problem is the one that can go away by itself, without treating or with minimal short-time treatment.
    In this case, for pharyngitis, Doctor rx'd medication, meaning, that It is not something that will go away by itself. By that said, the condition qualifies for 3 points (new problem) and since medication was prescribed, the risk is Moderate.
    The other thing is that, the level of service does not only come from MDM.
    I understand, that the MDM is the most important part of the LOS. The MDM can be SF, but if Doctor documented Detailed hx and Detailed PE then the overall LOS would be 99214, regardless of SF MDM.

    Lilit
    Last edited by HCCCoder; 08-14-2008 at 02:15 PM.
    CPC CCS
    "The true way to render ourselves happy is to love our work and find in it our pleasure."

  2. #12
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    Per CMS, MDM must be one of the two components met to determine level of service. Therefore a SF MDM with detailed hx and exam = 99212.
    Lisa Bledsoe, CPC, CPMA

  3. #13
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    Quote Originally Posted by ARCPC9491 View Post
    I've always had a hard time explaining my thoughts..... LOL

    Ok, you have a patient (new or established) with a minor/self limited problem (patient presenting for the first time w/ this problem - not stable, improving, or worsening) Would you give credit for "self limited/minor problem" or "new problem, no work up"

    In order to come up with moderate mdm (based on problem and risk only - no data) you would have to atleast be using new problem and moderate risk which of course equals Moderate overall mdm. This is where I feel the misconception lies.

    Because - if no one were giving credit for a "self limited/minor" problem, why would they even have it on the mdm tables? thus, resulting in overcoding by using new problem, no work up planned. because if self limited/minor would be used...the overrall mdm would be of straightforward/minimal complexity... (with your rx for for mod risk) thus justifying my opinion that these types of conditions warrant lower level e/m's.
    (this all based upon the fact of course the other components are met)
    Under # of dx's and tx options, it states "self limited or minor (stable, improved, or worsening)" which indicates it is a follow up to a previous visit...if it's the first time the provider is seeing the patient for the problem, it is "new" to the provider...
    Lisa Bledsoe, CPC, CPMA

  4. #14
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    I respectfully disagree with the posting that said self limited/minor conditions should not require prescriptions and should go away on their own w/o rx management... because if you look in the table of risk the examples they give for self limited are problems like colds, insect bites, tinea corposis.....colds receive rx's, as do insect bites, and ring worm, which also is treated by rx's.


    Problem Points

    Self Limited/Minor ............................ 1 point
    Est. prob........stable or improving........1 point
    Est. prob........worsening....................2 points
    New prob, no work up........................3 points
    New prob, work up............................4 points


    There's no distinction whether self limited/minor is est. or new.......
    So...... what to do?? If you always use "new prob, no work up...." for something that very well could be classified as "self limited/minor" the MDM component is higher than it should.........

    I do agree that self limited probs can also be new problems....HOWEVER, new problem or not - they should be classified as self limited - this better justifies the medical necessity of the issue....

    For all the posts about the hx and ex... I KNOW they are also key components of E/M and they have to be met as well depending on the type of E/M....which also help support medical necessity. I also understand that the hx or ex can bring you up or take you down depending on the MDM. But when you actually taking the MDM in account to determine the level, if you have moderate (because you used new prob and rx) when it should be minimal (if you have 1 Self limited or minor problem and rx) or Low (if you had 2 Self Limited or minor problem and rx) this is when it makes a difference because the overrall level will be overcoded.



    ..........Opinions?? Anyone??
    Last edited by ARCPC9491; 08-14-2008 at 12:46 PM. Reason: change.

  5. #15
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    This replies to ARCPC9491
    Well, for est. pt even though the MDM is SF, but you have detailed hx and PE, CPT book clearly states that for level 4, 2 out of 3 must be met (hx, pe, mdm). Therefore, since your Hx and PE are level 4, then your overall LOS is 99214. The truth is truth, there is nothing you can do. I heard CMS is going to change the tools, the MDM part is going to be the first and maybe after that they would say that the 2 out of 3 components must be the MDM. Until we receive the notice, we ARE NOT allowed to change the rules.
    It is different for a new pt, because 3 out of 3 components must be met. In the case where provider documented level 4 Hx, PE and SF MDM, the LOS will drop down to 99201.

    Can Lisa provide with a link or a file from CMS that states MDM must be one of the two components met to determine level of service? From my years of experience and from the school too, I didn't study this.
    Last edited by HCCCoder; 08-14-2008 at 02:14 PM.
    CPC CCS
    "The true way to render ourselves happy is to love our work and find in it our pleasure."

  6. #16
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    Quote Originally Posted by lmartirosyan View Post
    This replies to ARCPC9491
    Well, for est. pt even though the MDM is SF, but you have detailed hx and PE, CPT book clearly states that for level 4, 2 out of 3 must be met (hx, pe, mdm). Therefore, since your Hx and PE are level 4, then your overall LOS is 99214. The truth is truth, there is nothing you can do. I heard CMS is going to change the tools, the MDM part is going to be the first and maybe after that they would say that the 2 out of 3 components must be the MDM. Until we receive the notice, we ARE NOT allowed to change the rules.
    It is different for a new pt, because 3 out of 3 components must be met. In the case where provider documented level 4 Hx, PE and SF MDM, the LOS will drop down to 99201.

    Can Lisa provide with a link or a file from CMS that states MDM must be one of the two components met to determine level of service? From my years of experience and from the school too, I didn't study this.



    I never said that MDM MUST be one of the two components to determine the level for established pt's- i said WHEN you are USING the MDM component as one of the TWO to determine the level. Example: you have no EXAM - so you must use MDM and HX or when you use MDM and EXAM with no HX.....


    MDM is ALWAYS in every note - whether it be from a billing/coding/documentation/compliance/ethical/legal/clinical standpoint- MDM will always be present. how many notes have you seen without an A/P? i have never seen one.

    Now, will you ALWAYS have a history and exam? (specific to established patient's) - no you won't ALWAYS have it. (to coding guideline standards) This is why I am saying - that when MDM is USED to determine the OVERALL LEVEL OF E/M - self limited/minor issues are often OVERCODED due to the fact the "new problem, no work up" is given instead of the "self/limited/minor condition" for the MDM component.

    Of course if the HX and EX justify a higher level w/o the use of MDM - then so be it - this is all about when MDM is USED as a determing factor. but if the HX and EX are the 2 components used - it still has to make sense. i guess i'm just wondering why the HX and EX would stand alone if it wasn't justified w/ MDM? which you resort back to - MDM
    Last edited by ARCPC9491; 08-14-2008 at 07:36 PM. Reason: change.

  7. #17
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    Woodland Hills, CA
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    I actually was asking Lisa, because she had the comment about the MDM being 1 of the 2 components met to determine the LOS (post # 12).
    I have never said that there can be notes without an A/P.
    And if you don't have an Exam and you must use MDM and Hx, or when you use MDM and Exam with no Hx, then, still, you have to use the element circled farthest to the left to obtain the correct LOS. And again, MDM does not make an important role here, unless your other component is lower than the MDM.
    CPC CCS
    "The true way to render ourselves happy is to love our work and find in it our pleasure."

  8. #18
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    Quote Originally Posted by lmartirosyan View Post
    This replies to ARCPC9491
    Well, for est. pt even though the MDM is SF, but you have detailed hx and PE, CPT book clearly states that for level 4, 2 out of 3 must be met (hx, pe, mdm). Therefore, since your Hx and PE are level 4, then your overall LOS is 99214. The truth is truth, there is nothing you can do. I heard CMS is going to change the tools, the MDM part is going to be the first and maybe after that they would say that the 2 out of 3 components must be the MDM. Until we receive the notice, we ARE NOT allowed to change the rules.
    It is different for a new pt, because 3 out of 3 components must be met. In the case where provider documented level 4 Hx, PE and SF MDM, the LOS will drop down to 99201.

    Can Lisa provide with a link or a file from CMS that states MDM must be one of the two components met to determine level of service? From my years of experience and from the school too, I didn't study this.
    Well, you have me hunting...one place I found supporting information is the Coding Edge http://www.aapc.com/memberarea/resou...em-coding.aspx
    I'll keep looking for the other locations/supporting documentation I have encountered. I too questioned this until I recently read several articles supporting this standpoint. I'll let you know when I find the others. It might have been in a PART B News article as well, and something is telling me to check out Noridian. Unfortunately I have a meeting to get to or I'd keep looking.
    Lisa Bledsoe, CPC, CPMA

  9. #19
    Talking
    I found a nice article.... Here's a clip from the AAFP:

    Medical necessity
    Medical decision making seems to have a special role in determining the level of a patient encounter, even though it's supposed to be weighted evenly with the history and exam. Charles Colodny, MD, a family physician practicing in Libertyville, Ill., who represents the Academy on the AMA CPT Advisory Committee puts it succinctly: "The carriers are well aware that a physician intent on upcoding can increase the level of the history and physical very easily. Medical decision making is something else entirely. This is where they're going to be looking."

    Dr. Price agrees wholeheartedly. In a newsletter for participating physicians in his region, he wrote, "It should be the complexity of the medical decision making process and the medical problem which is the most heavily weighted factor determining the E/M service level." Dr. Price made it clear in a subsequent conversation that he views the medical decision making component as a reality check on the other two key elements. While he recognizes that any two of the three can determine the overall level for an established patient visit, he says the physician who consistently "does a great history and a great physical on someone who has a cold" is asking for trouble.

    Here's your link .... http://www.aafp.org/online/en/home/p...decisions.html


    Bottom line is MDM supports the medical necessity of the rest of the visit and should therefore be the driving factor!

    Many practices have their own policies that MDM should be 1 of the 2 key components for established patients to ensure medical necessity is being MET!


    I rest my case.

  10. #20
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    Duluth, Minnesota
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    ARCPC9491 - nice link - you should read it again. I wasn't going to respond to this post again but here I go.

    The only thing your resting is the fact that "you" feel pharynigitis or otitis are self limited or minor issues.
    Some of us disagree with that. I'd never call pharyngitis a minor issue when the provider has decided to run labs and give a prescription. {in fact your article from Dr. Price hits on that very issue} I've seen a sore throat turn to strept and I've seen what strept can do - strept is NEVER minor! He also mentioned things I can't do, like: I can't code "vrs"... so his example of "hypothyroidism vs. anemia" would not help me...can't code it.
    You might want to re-read the posts also, it seems to me that those of us who responded to your original post NEVER disagreed with the fact that MDM should support medical necessity. In fact, quite the opposite, we all agree with that. Again, we seem to be disagreeing on where we'd mark the issue, under self limited or new.

    As coders we've all learned (or we will learn) that each facility we work for has their own inside rules. As for mine - my providers document accordingly. Some times that pharyngitis is a level 2, sometimes a level 3 and sometimes a level 4 - it just depends on patient, issues, and treatment.

    Resting the case, great idea! I agree to disagree on this issue.
    {that's my opinion on the posted matter}again
    Donna, CPC, CPC-H

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