Amount and/or complexity of data ordered/reviewed. “Data” is classified as pathology/laboratory testing, radiology, and medicine-based diagnostics. Pertinent orders or results could be noted in the visit record, but most of the background interactions and communications involving testing are undetected when reviewing the progress note. To receive credit:
- Specify tests ordered and rationale in the physician’s progress note or make an entry that refers to another auditor-accessible location for ordered tests and studies;
- Document test review by including a brief entry in the progress note (e.g. “elevated glucose levels” or “CXR shows RLL infiltrates”);
- Summarize key points when reviewing old records or obtaining history from someone other than the patient, as necessary;
- Indicate when images, tracings, or specimens are “personally reviewed”; and
- Summarize any discussions of unexpected or contradictory test results with the physician performing the procedure or diagnostic study.
Risks of complication and/or morbidity or mortality. Risk involves the patient’s presenting problem, diagnostic procedures ordered, and management options selected. It is measured as minimal, low, moderate, or high when compared with corresponding items assigned to each risk level (see Table 2). The highest individual item detected on the table determines the overall patient risk for that encounter.
Chronic conditions and invasive procedures pose more risk than acute, uncomplicated illnesses or non-invasive procedures. Stable or improving problems are not as menacing as progressing problems; minor exacerbations are less hazardous than severe exacerbations; and medication risk varies with the type and potential for adverse effects. A patient maintains the same level of risk for a given medication whether the dosage is increased, decreased, or continued without change. Physicians should:
- Status all problems in the plan of care; identify them as stable, worsening, exacerbating (mild or severe), when applicable;
- Document all diagnostic or therapeutic procedures considered;
- Identify surgical risk factors involving comorbid conditions, when appropriate; and
- Associate the labs ordered to monitor for toxicity with the corresponding medication (e.g. “Continue Coumadin, monitor PT/INR”).
Determining complexity of medical decision-making. The final complexity of MDM depends upon the second-highest MDM category. The physician does not have to meet the requirements for all three MDM categories. For example, if a physician satisfies the requirements for a “multiple” number of diagnoses/treatment options, “limited” data, and “high” risk, the physician achieves moderate complexity decision-making (see Table 3). Remember that decision-making is just one of three components in evaluation and management services, along with history and exam.
Beware of payor variation, as it could have a significant impact on visit-level selection.3 Become acquainted with rules applicable to the geographical area. Review insurer websites for guidelines, policies, and “frequently asked questions” that can help improve documentation skills and support billing practices.
Carol Pohlig is a billing and coding expert with the University of Pennsylvania Medical Center, Philadelphia. She is also on the faculty of SHM’s inpatient coding course.