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How to get the credit you deserve for medical decision-making

April 2006

Published in the April 2006 issue of Today’s Hospitalist

You spend vast amounts of time on medical decision-making, from ordering tests to talking to other physicians, but do you know how to make sure you’re getting full credit from payers for your efforts?

The question is important, because when it comes to choosing an appropriate evaluation and management code, medical decision-making accounts for one-third of your effort. As a result, how you calculate the time and mental energy you spend on medical decision-making can have a serious impact on your bottom line.

In this article, I’ll review the three factors that go into medical decision-making. This information will help you make sure you’re being appropriately compensated for the non-procedural services you provide patients.

Number of diagnoses and management options

To determine the complexity of your medical decisionmaking, start by thinking about the number of diagnoses and management options you consider when caring for patients.

One key to this process is documenting your assessment or clinical impression about the patient during the visit. Make sure your assessment, whether it’s an explicit statement about the patient or a more general impression, reflects the management services you perform on that particular date of service.

Each piece of documentation must stand on its own, and while you can directly refer to previous documentation, you must include the date of the previous visit and the specific component of the documentation to which you are referring.

As an example of how you can count diagnoses and management options when calculating a level of medical decision-making, consider a patient who presents with an established diagnosis. (The exact problem isn’t important for our purposes here.) Your documentation could show whether the problem is improved or stable, which physicians often describe as well-controlled or resolving.

If your patient meets any of these criteria, the scoring system from the Centers for Medicare and Medicaid Services (CMS) allows one point for each diagnosis in this category. If you were following a patient with stable or improved atrial fibrillation, diabetes mellitus, and hypertension, for example, the CMS scoring system would allow three points.

If your patient has an established diagnosis that is inadequately controlled, worsening or failing to change as expected, on the other hand, the CMS scoring system allows a total of two points for each diagnosis in this category. If you were following a patient with COPD exacerbation and community-acquired pneumonia who was not responding to current treatment for either condition, this would equal four points on the CMS scoring system.

The table, “Determining number of diagnoses and treatment options,” below, gives an overview of how this scoring system works.

Volume and complexity of data

The second factor in medical decision-making is the amount and complexity of data you review. The following list illustrates the number of points you can take for reviewing lab tests and diagnostic imaging studies, reviewing records and obtaining a patient history from the patient and others:

  • Review and/or order of clinical lab tests (1 point)
  • Review and/or order of tests in the radiology section of CPT (1 point)
  • Review and/or order of tests in the medicine section of CPT (1 point)
  • Discussion of test results with performing physician (1 point)
  • Decision to obtain old records and/or obtain history for someone other than patient (1 point)
  • Review and summerization of old records and/or obtaining history for someone other than patient and/or discussion of case with another health care provider (2 points)
  • Independent visualization of image, tracing of specimen itself itself (not simply review of report) (2 points)

If you use the above list to review your medical decision- making, you get an idea of just how quickly these points add up. Pulling old records for review, talking to other physicians about a patient’s care and obtaining a history from family members are all factors for which you should receive credit!

Risk of complications and death

The third factor you need to consider in determining your level of decision-making is the patient’s risk of complications and death. A document called the Table of Risk can help you assess the presenting problem, diagnostic procedures ordered and management options selected.

(This document is too large to reproduce here, but you can find a PDF version online. The table is located on page 50.)

The Table of Risk is fairly simple to use. Take the three categories “presenting problems, diagnostic procedures and management options “and decide whether the patient’s risk is minimal, low, moderate, or high for each. The highest risk assessment in any of three categories determines the patient’s overall risk.

Determining a level of decision-making

Now that you’ve reviewed the three factors that go into medical decision-making, you’re ready to choose on an overall level.

To qualify for a level of medical decision-making (straightforward, low-complexity, etc.), you must meet or exceed the requirements for that level in two of the three categories.

To illustrate how to use this chart, consider the following example: A patient has multiple diagnoses (moderate complexity), a moderate amount of data to be reviewed (moderate complexity), and high level of risk (high complexity). As a result, this patient is a moderate complexity visit.

Tamra McLain is coding manager for HRA Medical Management Inc. in San Diego. E-mail your documentation and coding questions to her, or send a fax to 215-997-9651. We’ll try to answer your questions in a future issue of Today’s Hospitalist.