Medical Necessity vs Complexity of MDM

I have a new Neurologist who has asked me a question I really could not answer. I use the Marshfield audit tool for E/M visits. He and I have reviewed the "number of problems/diagnosis", "amount of data ordered/reviewed" and the example of risk. He is asking what in medical necessity makes the difference between moderate and high risk? I have suggestsed the probability of immanent risk of loss of function or loss of life. Anyone else have any ideas, or better yet, documented sources?

Thanks,
Deb

re: Medical Necessity vs Complexity of MDM

High Complexity:
A COPD exacerbation and uncontrolled hypertension
A severe pneumonia with workup
Acute renal failure with workup
Worsening severe chronic kidney disease and uncontrolled hypertension
Stable severe chronic kidney disease, stable diabetes, but uncontrolled proteinuria
Stable severe chronic kidney disease, controlled hypertension, controlled diabetes, controlled proteinuria

re: Medical Necessity vs Complexity of MDM

Per SuperCoder:
How to Assess Medical Decision-making for High-level E/M Visits

- Published on Thu, Feb 02, 2001

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Reimbursement for an office visit increases dramatically when going from a level-four (99204, 99214) to a level-five (99205, 99215) evaluation and management (E/M) service. With an established patient office visit, for example, the transitioned, non-facility relative value unit (RVU) for 99214 is 2.06 versus 3.06 for 99215.

To distinguish what level of office visit the service qualifies as, internists need to look carefully at the complexity of medical decision-making (MDM) involved in the visit. In many cases, increased medical risk to the patient separates the high complexity of medical decision-making required in a level-five E/M visit from the moderate complexity required in a level-four visit.

MDM, according to the CPT® manual, refers to the complexity of establishing a diagnosis and/or selecting a management option. It should be the driving force behind the E/M encounter, says Janet Leinke, CCS, CPC-H, senior outpatient consultant for Laguna Medical Systems, a health information consulting, outsourcing and education services company headquartered in San Clemente, Calif. If a patient has a minor problem and the medical decision-making is straightforward or of low complexity, the history and examination will be simple and noninvasive. If the problem is more significant or life-threatening, the medical decision-making will be of moderate to high complexity.

HCFA has stated that medical decision-making should be measured according to the following three components:

1. The number of possible diagnoses and/or number of management options that must be considered. A moderate level of medical decision-making (as required for a level-four E/M service) calls for multiple diagnoses and/or treatment options to be involved, while a high level of medical decision-making (as required for a level-five E/M service) calls for an extensive number.

2. The risk of significant complications, morbidity and/or mortality, as well as comorbidities, associated with the patients presenting problem(s), the diagnostic procedure(s) and/or the possible management options. A moderate level of medical decision-making calls for a moderate amount of medical risk, while a high level of medical decision-making requires a high amount of risk.

3. The amount and/or complexity of medical records, diagnostic tests, and/or other information that must be obtained, reviewed and analyzed. A moderate level (four) of medical decision-making calls for a moderate amount of data to be reviewed while a high level (five) of medical decision-making requires an extensive amount.

Decision-making must meet or exceed two of these three components.

Risk of Significant Complications Is Key

The risk of significant complications from the patients presenting problem(s), the diagnostic procedure(s) and/or the possible management options selected establishes the level of MDM. Both HCFAs 1995 and 1997 Guidelines for Documentation of Evaluation and Management Services categorize and define the level [...]

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