medical necessity and decision making

I've only recently started using the point system for determining medical decision making...a few questions. I was asked to see a patient by a primary for cholecystitis...The patient was young and relatively healthy without risk factors. I gave 3 points for problem (new problem, no work-up planned). I personally reviewed the patients admission lab tests and ultrasound (1+2 for data review). I decided that the patient needed a laparoscopic cholecystectomy and counted this as moderate risk (elective major surgery without risk factors)...That makes this moderate medical decision making...If I do a comprehensive history and exam, then this visit is coded as 99254. Is this correct? If so I've been undercoding for the past 2 years. The other question has to do with necessity...What determines this? Is it the medical decision making? Could an auditor argue that I didn't need to do a comprehensive history or exam for this patient? Thanks for any feedback.

medical necessity and decision making

I agree: that is moderate MDM and with a comprehensive history and exam is a 99254.

The CMS statement on medical necessity if brief:

Medical necessity of a service is the overarching criterion for payment in addition to the individual requirements of a CPT code. It would not be medically necessary or appropriate to bill a higher level of evaluation and management service when a lower level of service is warranted. The volume of documentation should not be the primary influence upon which a specific level of service is billed.

It doesn't give us a lot of help. The nature of the presenting problem should require level of history and exam, but except in the obvious cases, I don't find it much help. (do you need a comprehensive history and exam before performing a minor office procedure? of course not. But for any surgery? Many physicians would say yes.)

I did add an article about MDM with a sample audit sheet from one of the carriers.

http://www.codapedia.com/~article_370_.cfm

medical decision making and medical necessity

Thanks for the mdm post...but I'm still a bit confused. I reviewed the audit sheet from top to bottom, and there's nothing there that guides the auditor with regards to medical necessity...its simply a checklist of what's in the medical record. One could simply overdocument a mole and based on the audit sheet, code at a level 3. For example, I'm asked to see a patient in the office in consultation for a "mole" on the back which requires excisional biopsy. This is a new problem to me, and I'm not planning on further work-up (3 points). No data to review (0 points). And minor surgery with no risk factors (low risk). The MDM would be low complexity...qualifying for a level 3 consult...All I would have to do is do a detailed history and detailed physical and I could bill at a level 3....for a mole. Is this correct? Who determines medical necessity...did I really need a detailed history or physical...when all I had to do is simply look at the mole.

Second question. What's the difference between minor problem and new problem no workup required. If I'm asked to see a new patient in consultation in the office for a boil, is this a minor problem, or new problem no work-up needed? After all, its a new problem to me. That's 3 points, no data to review (0 points) and minor surgery without risk factors (for incision and drainage). Again this would be a level 3. Or do I give this 1 point for minor problem?

Third question. In the "mole" example, if I don't know the malignant potential and plan on excisional biopsy, does this count as "work-up planned" or is the biopsy simply the surgery and therefore counted in the risk category?

Last question (promise). For the Data section of MDM, if the patient has a CT scan and plans on forwarding it to me after his visit...say a few days later for my review...can I count this prospectively knowing I will review it...or does it only count if reviewed on the day of the consult visit.....I have a specific example. I saw a patient in the hospital in consultation for a "cecal mass". She had presented to another hospital with abdominal pain, had gotten a CT scan and was discharged from the ER only to present to this other hospital a few days later. I have previliges at both hospitals. I saw the patient at hospital A wrote my consult note, and later that day reviewed her CT at hospital B. If I documented the CT results the following day in her chart, can I count that as "image reviewed". This is sometimes the difference in going to a higher level of care.

I hope I didn't beat this to death... :)

medical decision making

You can overdocument all you want but if audited will be held to medical necessity not volumn. If, in your opinion the mole is straightforward MDM, then the level is probably 2. MDM drives the level of coding, in my opinion. "Guidelines" as issued by CMS are just that, a guide to help in selection of the code. You code what is medically necessary based on the presenting problem(s), no more and hopefully, no less. The provider makes that decision. The medical record is your silent witness and must stand on its own for each encounter. Minor surgery is a moderate risk but is only one component of the risk chart, you still must determine the risk of the presenting problem and the risk of tests ordered/reviewed. This result is then added to the other two component (number of diagnosis and complexity of data) to arrive at level of MDM. If the H&P does not require a detailed level, then it will be a problem focused or expanded problem focused encounter (must meet or exceed 3 of 3 key components). The PHYSICIANM determines medical decision making and it's complexity.
A minor problem is a problem that runs a definite and prescribed course, is transient in nature, and is not likely to permanently alter health status or has a good prognosis with management and compliance. if there is a potential for additional workup then additional workup is planned (if necessary based on biopsy).
review of data must be reviewed with patient on day of encounter face to face to qualify.

Just to add to the excellent discussion

CMS added a clarification about medical complexity because of EMR's. With a few clicks you can document a comprehensive Hx, ROS and PE on a patient with a mole and that would meet the 2 of 3 categories for a level V followup visit but we all know that a mole is not a level V problem. So CMS came out and said that the complexity of the presenting problem is the key in determining the level of visit. I have the exact reference on another computer if you need it.

Just to add to the excellent discussion

Of course we want the CMS citation from your other computer, but don't tell your staff why you're slipping out! Tell them you have to go review an image for a patient you're going to see so they don't get mad at us.....:)

Here is the reference

[Of course we want the CMS citation from your other computer, but don't tell your staff why you're slipping out! Tell them you have to go review an image for a patient you're going to see so they don't get mad at us.....:)]



Medical necessity of a service is the overarching criterion for payment in addition to the individual requirements of a CPT code. It would not be medically necessary or appropriate to bill a higher level of evaluation and management service when a lower level of service is warranted. The volume of documentation should not be the primary influence upon which a specific level of service is billed. Documentation should support the level of service reported. The service should be documented during, or as soon as practicable after it is provided in order to maintain an accurate medical record

from: http://www.cms.hhs.gov/transmittals/downloads/R178CP.pdf

omplexity of presenting problem

If it is not too much trouble, could you provide the exact reference for the statement of the complexity of the presenting problem being the determining level of a visit.

Mdm

Medical decision making is generally easier for an already diagnosed problem than for an undiagnosed one. In addition, problems which are improving or resolving are less complex than those which are worsening or failing to change. Keep in mind that MDM should reflect the nature of the presenting problem. Treatment for a common ailment, such as an ordinary cold, will not usually warrant a comprehensive level exam.
Medical Decision-Making ( MDM ) reflects the intensity of the cognitive labor performed by the physician.
Point System:
Medicare discovered that auditors were having a hard time nailing down the level of Medical Decision-Making during the medical review process. In response to this problem, a more objective Medical Decision-Making Point System was developed by CMS . Although not part of the official E/M guidelines, this MDM Point System was distributed to all Medicare carriers to be used on a "voluntary" basis. In point of fact, this is the way your Medical Decision-Making will be graded in the event of an audit.
The determining factor in selection of appropriate E/M is not exclusive to MDM. It will be based on 2 of 3 or 3 of 3 key components,

http://www.wpsic.com/medicare/part_b/education/eandm_decision.shtml

medical decision making

Thanks for all the feedback. One question I still don't have a clear answer for is how does the auditor determine medical necessity? I just saw a patient as an office consultation with what appeared to be prostatitis. This was a new problem to me, with no additional work-up (3 points), no data to review, and treatment with prescription antibiotics (moderate risk). This makes it a moderate MDM which would qualify for 99254 if I do a comprehensive history and exam (which I did). Could I code this at a 99254? And here's the part I don't really have an answer for...how does the auditor know whether this was medically necessary? There's nothing in the sample auditing form which would guide the auditor on this topic.

I think I have a better handle on the issue of problem points...except for the topic of minor problem and new problem, no work up required. In the example above, some would argue that the problem is really self limited and will resolve with antibiotics. However, when I see any new consult in the office, it is always a new problem to me (with or without further workup). So is it safe to assume, that no matter the problem, if I'm seeing it for the first time in consultation then I would automatically get 3 points for this?

MDM and medical necessity

I presume that your question of medical necessity is in the context of documentation guidelines of E/M. Medical Necessity is defined as services which are "reasonable and necessary" or "appropriate" in light of clinical standards of practice. For example, if a patient came in for a blood pressure check and has well controlled HTN could you bill a level 5 visit just because you documented a level 5 visit? The answer is no since the diagnosis and treatment would not warrant a level 5 visit.

The physician has the say whether something was medically necessary and as long as you can justify clinically why a level of visit was medically necessary there is no problem.

The OIG looks for "out-liers", which fortunately for all of us, are rare. Use your best medical judgement and let your documentation fit the problem, age, comorbidities of your patients.

Medical Necessity also plays a role for diagnosis vs treatment. For instance, a joint injection would not fit with a diagnosis of Diabetes; medical necessity for arthrodesis would be arthritis or some other joint problem.

Alyce Kalb CPC CCS-P CMMr

MDM and medical necessity

You are absolutely right: there is nothing that guides us to medical necessity.

For the mole: I do think the medical decision making would be low: new problem to you, one data point for the pathology, and for risk, minor surgery. Low MDM is the level for a 99213, or for a new patient, a 99203. Would you have a detailed history and exam? In my experience auditing notes, the exam would be the limiting factor in this note, and would not be detailed. (I'm not saying yours isn't, only that what I tend to see for new patients with minor procedures is an expanded problem focused exam.)

I count minor problems as those that are "Self-limited or minor." The blue E/M section of the CPT book describes this under nature of the presenting problem, as, "A problem that runs a definite and prescribed course, is transient in nature, and is not likely to permanently alter health status OR has a good prognosis with management/compliance." As I think of it, if you felt the boil did not need intervention or treatment, I'd call it a minor problem, and you'd have straightforward MDM, the level required for a 99212 for established or 99201 or 99212 (depending on the history and exam) for new. Boil with no intervention: minor problem, no data, minimal risk, straightforward MDM.
Boil with incision and drainage: new problem, no data (?cultures) and minor surgery which is low risk, is low MDM.

Mole with work up planned: I would call this work up planned. You are waiting for information that you ordered at this visit, which will not be available by the end of the visit.

The last question calls for an opinion, because the guidelines are not specific enough for this level of example. At the time of the fisit at Hospital A, I would count one point for ordering the test/ordering the results of the test be sent to you. For the consult, you would get 1 data point, from your example. The next day, when you billed a subsequent hospital visit, and reviewed the image yourself, you get two points.

We E/M people live by this stuff!

..

[I've only recently started using the point system for determining medical decision making...a few questions. I was asked to see a patient by a primary for cholecystitis...The patient was young and relatively healthy without risk factors. I gave 3 points for problem (new problem, no work-up planned). I personally reviewed the patients admission lab tests and ultrasound (1+2 for data review). I decided that the patient needed a laparoscopic cholecystectomy and counted this as moderate risk (elective major surgery without risk factors)...That makes this moderate medical decision making...If I do a comprehensive history and exam, then this visit is coded as 99254. Is this correct? If so I've been undercoding for the past 2 years. The other question has to do with necessity...What determines this? Is it the medical decision making? Could an auditor argue that I didn't need to do a comprehensive history or exam for this patient? Thanks for any feedback.]

MDM and the point system

I would audit this as moderate medical decision making. I absolutely agree with the way you've arrived at it. If you feel it is medically necessary to do a comprehensive history and exam (which is what I see for a patient going to surgery) and you document all of the components, you can bill a 99204/99244/99254 depending on correct category of service.

There are some surgeons who do a more focused exam, or don't take a complete ROS, and then have to bill at a lower level.

http://www.codapedia.com/~article_370_.cfm

Watch your profile and compare with the norm for your specialty. Don't bill 95% of your new patients or consults as level four, because it increases the likelihood of an audit.

http://www.codapedia.com/~article_76_.cfm

http://www.codapedia.com/~article_344_.cfm