What are the guidelines for selecting the level of E/M service based upon Medical Decision Making (MDM)?
• E/M codes that have levels of services include a medically appropriate history and/or physical examination, when performed. The nature and extent of the history and/or physical examination are determined by the treating physician or other qualified health care professional reporting the service. The care team may collect information, and the patient or caregiver may supply information directly (eg, by electronic health record [EHR] portal or questionnaire) that is reviewed by the reporting physician or other qualified health care professional. The extent of history and physical examination is not an element in selection of the level of these E/M service codes.
• Medical decision making includes establishing diagnoses, assessing the status of a condition, and/or selecting a management option. Medical decision making is defined by three elements:
- 1. The number and complexity of problem(s) that are addressed during the encounter
- Definition of a problem:
- • A problem is a disease, condition, illness, injury, symptom, sign, finding, complaint, or other matter addressed at the encounter, with or without a diagnosis being established at the time of the encounter.
- • Comorbidities/underlying diseases, in and of themselves, are not considered in selecting a level of E/M services unless they are addressed, and their presence increases the amount and/or complexity of data to be reviewed and analyzed or the risk of complications and/or morbidity or mortality of patient management.
- 2. The amount and/or complexity of data to be reviewed and analyzed. This data includes medical records, tests, and/or other information that must be obtained, ordered, reviewed, and analyzed for the encounter. This includes information obtained from multiple sources or interprofessional communications that are not separately reported. It includes interpretation of tests that are not separately reported. Ordering a test is included in the category of test result(s) and the review of the test result is part of the encounter and not a subsequent encounter.
- A. Tests, documents, orders, or independent historian(s). (Each unique test, order or document is counted to meet a threshold number)
- B. Independent interpretation of tests
- C. Discussion of management or test interpretation with external physician or other qualified healthcare professional or appropriate source
- 3. The risk of complications, morbidity, and/or mortality of patient management decisions made at the visit, associated with the patient’s problem(s), the diagnostic procedure(s), treatment (s). This includes the possible management options selected and those considered, but not selected, after shared medical decision making with the patient and/or family. For example, a decision about hospitalization includes consideration of alternative levels of care. Examples may include a psychiatric patient with a sufficient degree of support in the outpatient setting or the decision to not hospitalize a patient with advanced dementia with an acute condition that would generally warrant inpatient care, but for whom the goal is palliative treatment.
- • Four types of Medical Decision Making are recognized: straight forward, low, moderate, and high.
- • Shared Medical Decision Making involves eliciting patient and/or family preferences, patient and/or family education, and explaining risks and benefits of management options.
- • Medical Decision Making may be impacted by role and management responsibility.
- • When the physician or other qualified health care professional is reporting a separate CPT code that includes interpretation and/or report, the interpretation and/or report should not be counted in the Medical Decision Making when selecting a level of E/M service. An example would be obtaining and interpreting X-rays in the office.
- • When the physician or other qualified health care professional is reporting a separate service for discussion of management with a physician or other qualified health care professional, the discussion is not counted in the Medical Decision Making
This is my opinion.
Michael G. Warshaw
DPM, CPC
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