Newsletter - JAN 2012
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Medical Decision Making
The Medical Decision Making (MDM) component of the documentation is arguably the most important of the three key components - History, Exam & MDM in assigning an E/M service level. The MDM reflects the intensity of the cognitive labor performed by the physician.
There are four levels of MDM of incrementally increasing complexity:
- Straightforward
- Low Complexity
- Moderate Complexity
- High Complexity
These levels of complexity are based upon:
- The nature and number of clinical problems
- The amount and complexity of the data reviewed by the provider
- The risk of morbidity and mortality to the patient
The "Level of Risk" is determined by scoring each of the three categories:
- Presenting problem (not diagnosis - presenting problem(s) managed by the ED physician!)
- Diagnostic procedures ordered
- Management options selected
Each category is scored by complexity - Minimal Risk, Low Risk, Moderate Risk or High Risk, and two of the three must meet or exceed the overall level of risk selected. Selecting the E/M service level is more than just adding up elements of the physical exam and history. With the implementation of Electronic Medical Records, it's very common to see a comprehensive history and exam documented for low level E/M services. (This raises an issue for a separate article at a later date.) Coders will rely on the MDM component to select the appropriate E/M service level. It is ultimately the physician's thought process that assists coders in assigning the level of service as the final diagnosis tells just a small part of the story. For example, if a physician documents headache (784.0) as the final diagnosis, this would usually start out as a low-moderate complexity in the coders mind. Now, it's up to the physician to tell the rest of the story!
Here are some tips for documenting Medical Decision Making:
- List your impressions and differential diagnoses
- Document pertinent contents of any old medical records reviewed
- List all interventions and procedures, medications including route of administration, response to treatment, changes in status that may outweigh presenting problem
- Document pertinent details of discussions with PCP and/or consultants
- Record EKG and/or imaging studies, indicating "per my interpretation" if applicable
- Document impression of ancillary test results
- Record discharge instructions including medications, and follow-up
- Give a definitive time frame for a phone or office follow-up
- Document the diagnosis(es) and list all that are pertinent
- Remember to note "acute" or "emergent" when applicable
- Review Nurses Notes for accuracy in supporting orders, interventions, disposition
Ultimately, the purpose of the MDM is to let us know how you got from the presenting complaint through the evaluation and management to the disposition of the patient. A well-documented MDM will not only increase reimbursement but will also safeguard you from inevitable audits. Today it's when, not if, audits will occur, so take care to document well.
Written by Debora Butcher, CPC
Wound Repairs of the Lips
Lacerations of the lips are injuries commonly seen in the Emergency Department. Because of the delicate tissues involved and the cosmetic considerations of this highly visible area, the repair can be very difficult. The exact location and extent of the repair in question will determine how to select the right code. In this article we will focus specifically on lacerations through the vermilion border.
The vermilion border refers to the line where the lips stop and the adjacent facial skin begins, usually easily determined by the change in color and texture. The CPT Code descriptors for repair of the lip involving the vermilion border along with the RVU assignment are as follows:
In order to use the anatomical repair codes, the repair must be full thickness along with involvement of the vermilion border. For a simple repair involving the vermilion border the appropriate code would be; 1201x - Simple repair of superficial wounds of face, ears, eyelids, nose, lips and/or mucous membranes. As you can see from the table above, there is a considerable and deserving reimbursement difference between these three different repairs and a superficial facial/lip repair. A coder cannot jump to conclusions about the repair performed; the verification to assign the most appropriate code can only be found in the documentation.
When documenting your procedure note, it is important to document how much of the vertical height of the lip was repaired. Because the size of lips vary, the descriptor code does not use exact lengths but rather breaks the codes down in vertical height (vermilion only, up to half, and over one-half). You will also need to document if it was a full thickness repair, to include the layers repaired, suture material used, etc. In summary, remember to document all details of the closure to ensure the most appropriate and specific CPT code can be determined by the coder.
Written by Debora Butcher, CPC
