Coding and Billing

Avoid Coding & Billing Errors By Using Medical Decision-Making

By Mark Wright, OD, FCOVD

March 1, 2017

Medical decision making (MDM) is used for 99000 E/M coding. Of the three areas necessary for coding the 99000 E/M series – history, physical examination and medical decision making – MDM is the most difficult. We’ll try to make it easier with this article.

There are four levels of MDM coding: Straightforward, Low Complexity, Moderate Complexity and High Complexity. To determine which is the appropriate level, the rules say to choose two of the following: (1) Number of Diagnoses or Management Options; (2) Amount and/or Complexity of Data; (3) Level of Risk.  The table you will use is given here.

Even though the rules say pick any two of the three columns to code MDM, if you want to code like an auditor, then, always use Risk as one of your two and then select the highest of either (1) Number of Diagnoses or Management Options; (2) Amount and/or Complexity of Data.

RISK
Let’s look at Level of Risk first. There is a Table of Risk in the CPT coding definitions, but the coding guidelines do not give good examples for eyes.

There are four levels of Risk: Minimal, Low, Moderate and High. Here is the criteria for each level.

Minimal Risk is one self-limited or minor problem. A subconjunctival hemorrhage on a healthy 25-year-old who rubbed their eyes too hard on awakening today would be a good example of this level of risk.

Low Risk would be two or more self-limited or minor problems, one stable chronic illness, acute uncomplicated illness or injury, or prescribing over-the-counter drugs for the patient. A stable anterior subcapsular cataract would be a good example of this level of risk.

Moderate Risk would be one or more chronic illness with mild exacerbation, progression or side effects of treatment; two or more stable chronic illnesses; undiagnosed new problem with uncertain prognosis; acute illness with systemic symptoms; acute complicated injury; prescribing minor surgery with identified risk factor; or prescribing drugs.

High Risk is one or more chronic illness with severe exacerbation, progression or side effects of Tx; acute or chronic illness or injuries that pose a threat to life or bodily function; an abrupt change in neurological status (seizure, TIA, weakness, sensory loss); elective or emergency major surgery; or drug therapy requiring intensive monitoring for toxicity.

To simplify this for clinical thinking, High Risk can be thought of as death of the patient, death of the eye, or permanent loss of vision. Moderate Risk is any time you pull out your prescription pad to write a prescription for something the patient cannot get over the counter. (But, keep in mind the rest of the definitions are always in play.)

Number of Diagnoses or Management Options
There are two ways to determine the level of Number of Diagnoses or Management Options. The first way is the easiest – you simply count the number of diagnoses or management options. One diagnosis or management option is Minimal Level, two is Limited Level, three is Multiple Level, and 4 or more is Extensive Level.

Another way to determine the Number of Diagnoses or Management Options is to try to infer complexity from the nature of the problem and the degree of effort addressing it will take. One such method is the Marshfield Clinic Scoring Tool. You can read about it HERE.

Amount and or Complexity of Data to be Reviewed
To code for Amount and or Complexity of Data to be Reviewed, use the chart below.

Count the number of points for the patient in front of you. One point is Minimal Level, two is Limited Level, three is Multiple Level, and 4 or more is Extensive Level.

Let’s put it all together. If the patient in front of you needed you to write a prescription, the Risk Level would be Moderate. If the patient had 4 or more diagnoses or management options, the Number of Diagnoses or Management Options would be the highest level – Extensive. Going to the chart below, the Level of Medical Decision Making would be Moderate Complexity.

Note that because the Number of Diagnoses or Management Options was equal to or higher than the Risk Level, we didn’t even need to look at the middle column – Amount and or Complexity of Data to be Reviewed.  Calculating the Amount and/or Complexity of Data to be Reviewed would not have raised the Medical Decision Making Level in this example.

Now that you know how to code for MDM, don’t forget to document this in your medical records so even a fifth grader can follow how you arrived at your MDM level.

 

References
i. https://www.aliem.com/2016/charting-and-coding-medical-decision-making/

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