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Medical Decision Making - risk component

  1. #1
    Default Medical Decision Making - risk component
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    I have read tons of the postings on here regarding E/M...one of the obvious things I see is regarding Medical Decision Making and the risk component.

    Just because you have a "new problem" and a "prescription" doesn't necessarily mean the overrall Medical Decision Making is of Moderate....which as we know correlates to a level 4 (given the history, exam are sufficient for the type of E/M)

    For example, I've seen a ton of notes where people are giving level 4's for pharyngitis or otitis media just because it's a new problem and they gave a prescription. Most providers would agree that for these problems, the Medical Decision Making is of Low Complexity. It is commonly routine to give prescriptions for these types of conditions.

    Even though "the table and points system" gives you a Moderate Decision Making, doesn't mean it's a level 4. No tables or points can justify medical necessity - which of course is the number #1 key component of all.

    So next time you see a patient for a minor condition that requires a prescription.....re-evaluate your decision to go with Moderate decision making.... I believe most people would agree you are overcoding.

  2. #2
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    Quote Originally Posted by ARCPC9491 View Post
    I have read tons of the postings on here regarding E/M...one of the obvious things I see is regarding Medical Decision Making and the risk component.

    Just because you have a "new problem" and a "prescription" doesn't necessarily mean the overrall Medical Decision Making is of Moderate....which as we know correlates to a level 4 (given the history, exam are sufficient for the type of E/M)

    For example, I've seen a ton of notes where people are giving level 4's for pharyngitis or otitis media just because it's a new problem and they gave a prescription. Most providers would agree that for these problems, the Medical Decision Making is of Low Complexity. It is commonly routine to give prescriptions for these types of conditions.

    Even though "the table and points system" gives you a Moderate Decision Making, doesn't mean it's a level 4. No tables or points can justify medical necessity - which of course is the number #1 key component of all.

    So next time you see a patient for a minor condition that requires a prescription.....re-evaluate your decision to go with Moderate decision making.... I believe most people would agree you are overcoding.
    I have to respectfully disagree with your comment. It is what it is. New problem DOES get a 3 - (4 if there's work-up planned),labs are usually done, sometimes xrays - and a prescription given DOES give it a higher Risk Factor. That being said - MDM "alone" does not determine "medical necessity"... Often the MDM is MOD - and the HPI and EXAM are PF - which of course brings the E/M level down (not level 4).
    The determination of the E/M level is based on the components of each element. High or low levels for pharyngitis or otitis depending on what documentation supports. (the combination of the HPI/EXAM/MDM).
    So, just because it's "only" pharyngitis or otitis - doesn't mean it doesn't support a level 4.
    {that's my opinion on the posted matter}
    Donna, CPC, CPC-H

  3. #3
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    I totally agree with Donna,
    Thank you!
    CPC CCS
    "The true way to render ourselves happy is to love our work and find in it our pleasure."

  4. #4
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    I also agree 100% with Donna!

  5. #5
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    I guess I'm a little confused by your response, Donna.

    Medical Necessity is first and foremost the #1 factor any ANY service rendered by a physician - regardless of how well documented anything is.

    A physician could document a complete hx, ex, and take mdm to the max on every patient, but is that really necessary? I think not.

    Any medicare manual will advise against this as it is not deemed medically necessary.

    So you're telling me, you would do a comprehensive history and comprehensive exam on a patient who has a self limited/minor problem such as otitis media or pharyngitis? (with the reference to new level 4) I beg to differ.

    I understand that the tables states if you have a new problem with a rx it is a moderate level of mdm...however...mdm cannot be truly determined without the clinical judgement of the provider...thats why EMR's and coders who do not have the skill and knowledge of the MD, interpret things in different ways...thus producing different results....

    I guess what I'm trying to say is most of these simple/minor problem patients are coded as level 4's when rather they should be 3's.
    Last edited by ARCPC9491; 08-13-2008 at 03:17 PM. Reason: added info

  6. #6
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    Quote Originally Posted by ARCPC9491 View Post
    I guess I'm a little confused by your response, Donna.

    Medical Necessity is first and foremost the #1 factor any ANY service rendered by a physician - regardless of how well documented anything is.

    A physician could document a complete hx, ex, and take mdm to the max on every patient, but is that really necessary? I think not.

    Any medicare manual will advise against this as it is not deemed medically necessary.

    So you're telling me, you would do a comprehensive history and comprehensive exam on a patient who has a self limited/minor problem such as otitis media or pharyngitis? (with the reference to new level 4) I beg to differ.

    I understand that the tables states if you have a new problem with a rx it is a moderate level of mdm...however...mdm cannot be truly determined without the clinical judgement of the provider...thats why EMR's and coders who do not have the skill and knowledge of the MD, interpret things in different ways...thus producing different results....

    I guess what I'm trying to say is most of these simple/minor problem patients are coded as level 4's when rather they should be 3's.
    I agree with Donna - and I did not see anything in her comment that she would condone a comprehensive history and exam on a patient with a self limited or minor problem. Documentation must support the level of service AND must be medically necessary. In the pharyngitis example, the "clinical judgement of the provider" could be to prescribe medication or just OTC treatment. The risk in giving an RX is substantially greater than just telling the patient to take ibuprofen. So yes, if you do not prescribe medication in this scenario you most likely are looking at a 99213 because you probably have a detailed history, EPF (or even just PF) exam, and low MDM. BUT if the provider prescribes medication, the MDM does become moderate based on the RISK involved - so if you have a detailed history, and a simple PF exam, but Moderate MDM - you are looking at 99214. It's all in the documentation and the medical necessity.
    Lisa Bledsoe, CPC, CPMA

  7. #7
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    Quote Originally Posted by ARCPC9491 View Post
    I guess I'm a little confused by your response, Donna.

    Medical Necessity is first and foremost the #1 factor any ANY service rendered by a physician - regardless of how well documented anything is.

    A physician could document a complete hx, ex, and take mdm to the max on every patient, but is that really necessary? I think not.

    Any medicare manual will advise against this as it is not deemed medically necessary.

    So you're telling me, you would do a comprehensive history and comprehensive exam on a patient who has a self limited/minor problem such as otitis media or pharyngitis? (with the reference to new level 4) I beg to differ.

    I understand that the tables states if you have a new problem with a rx it is a moderate level of mdm...however...mdm cannot be truly determined without the clinical judgement of the provider...thats why EMR's and coders who do not have the skill and knowledge of the MD, interpret things in different ways...thus producing different results....

    I guess what I'm trying to say is most of these simple/minor problem patients are coded as level 4's when rather they should be 3's.
    to clarify, I didn't say that medical necessity wasn't a factor in the service provided by the physician - that's obvious (it's why the patient is coming in, for medical treatment of some sort) - what I said was: "MDM "alone" does not determine "medical necessity".
    that being said (again)
    ... I'm not saying I'd do a comprehensive history and comprehensive exam on a patient who has a self limited/minor problem such as otitis media or pharyngitis,*I* wouldn't do a comprehensive anything (the provider would). So if my physician documents a history and exam that is pertinant to the reason the patient is in - and it meets the components in each element, making it detailed or comprehensive then YES - if it supports the level 4 that's what I would code it out to....yes (again)
    To go further, just because a provider documents 3 pages does not mean it's an automatic high level E/M. same/same for short documentation - it doesn't automatically mean it's a low level - it all depends on what the documentation supports.
    As for determining MDM - the clinical judgement of the provider is "IN" the documentation (or should be), which is how we (coders) decide presenting problem, dx procedures ordered and management options selected, that help determine the level of MDM.
    I would agree that more often than not these simple issue are lower level E/Ms. As I said before - usually, the MDM is high and the HPI and EXAM are lower...equaling out to lower lever E/M "Often the MDM is MOD - and the HPI and EXAM are PF - which of course brings the E/M level down (not level 4)"
    respectfully -
    {still, my opinion on the posted matter}
    Donna, CPC, CPC-H

  8. #8
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    Duluth, Minnesota
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    I agree with Lisa: simply said
    "It's all in the documentation and the medical necessity."
    {again, my opinion}
    Donna, CPC, CPC-H

  9. #9
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    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)

  10. Default
    You code your E/M by how well the doctor documents, not by the diagnosis.
    I agree it doesn't seem right, I'll have a COPD be a level 3 and ear ache become a level 4. It's all in the doctors documentation.

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