ED Coding Update: Learn the elements of risk for accurate MDM level
Learn the elements of risk for accurate MDM level
[Editor's note: This is the second column in a two-part series on the relationship between medical decision making and documentation. In the May issue, we covered the key components of medical decision making. This month we address risk as an element of decision-making. This quarterly column on ED coding is written by Caral Edelberg, CPC, CCS-P, CHC, president of Edelberg Compliance Associates in Baton Rouge, LA.]
The third element of medical decision making (MDM), risk, should be simple to evaluate, but familiarity with the elements of risk can help emergency physicians correctly interpret their overall MDM level to ensure that history and physical examination documentation meet or exceed the MDM level.
The "level of risk" is determined by scoring each of three categories: presenting problem [not diagnosis — presenting problem(s) managed by the ED physician]; diagnostic procedures ordered; and management options selected. Each category is scored by complexity, and two of the three must meet or exceed the overall level of risk selected.
• Category I: Presenting problem.
— Minimal low presenting problem: Note that the single self-limited, minor problem scores as minimal. Two or more self-limited, minor problems, stable chronic illnesses, and acute uncomplicated problems score as low.
— Moderate presenting problem: The progress up from these simple or minor single/multiple problems takes us to where the majority of ED levels fall: one or more chronic illnesses with mild exacerbation, multiple stable chronic illnesses, undiagnosed problems with questionable prognosis, acute systemic symptoms, and acute complicated injuries (illustrated as head injury with BRIEF loss of consciousness).
— High presenting problem: This section includes severe exacerbation of one or more illnesses, illnesses, or injuries that pose threat to life or body function. There is abrupt change in neurologic status.
• Category II: Diagnostic procedures ordered.
The procedures in this category illustrate the risk to the patient from performance of the procedure. Elements in this category rarely illustrate the appropriate level of risk for ED patients.
• Category III: Management options selected.
— Minimal/Low: Note simple medications, minor surgery with no risk factors (no antibiotics, etc.), and IV fluids without additives. This is tricky, but ED IVs generally don't fall in this category.
— Moderate: ED visits often start here. This includes minor surgery with prescription meds, prescription drug management, IV fluids with additives, and treatments consistent with a closed treatment of a fracture or dislocation without manipulation. Note, we are developing the E/M [evaluation/management] level that is billed IN ADDITION TO the actual procedure. The procedure "package" kicks in once the decision for surgery is made for this level of procedure.
— High: Emergency major surgery, parenteral controlled substances, intensive monitoring of drug therapy, and DNRs [do not resuscitate orders] qualify for high complexity management options that indicate high risk.
All of the components of the Medicare/American Medical Association documentation guidelines were assigned scores, or "points," subsequent to the official release of the guidelines.
The Marshfield Clinic scoring tool is the most common and was referenced by the Centers for Medicare and Medicaid/American Medical Association. Although point systems have not been officially endorsed, they are commonly used by payers, Medicare in particular, to score records on audit. Coders generally are familiar with scoring tools, but ED physicians often find them annoying. If it's possible, you must know what rules your carrier, MAC [maximum allowable cost and/or contracted payers are using to score the audits on your records. Today it's when, not if, audits will occur, so you want to clarify any of the ambiguous terms in the guidelines to be sure you are complying with your local carrier's interpretation.
Physicians understand MDM in the context of clinical justification: how they got from the presenting complaint through the ED course and management to disposition of the patient. Remember: Quality documentation and the justification of services inherent in the MDM are also tools to use in measuring quality and risk.
Tips for Documenting Medical Decision Making
Source: Caral Edelberg, CPC, CCS-P, CHC, President, Edelberg Compliance Associates, Baton Rouge, LA. |
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