E&M code – Determining complexity

Determining Complexity of Problems of E&M code

Providers now have the option of using time or MDM for reporting their E/M visits. The challenge has been teaching physicians and other qualified healthcare professionals a new way of documenting patient encounters — one that doesn’t rely on them checking off data elements.

Whereas time-based coding is any work on the date of the visit that isn’t separately reimbursed, MDM requires two of three elements for both new and established patients. Billing based on MDM requires providers and coders to not only recognize the various levels of MDM complexity, but also to understand and agree on their definitions.

For code selection, the number and complexity of problems are as follows:

99212/99202 Minimal One self-limited or minor problem
99213/99203 Low Two or more self-limited or minor problems or one stable, chronic illness or one acute, uncomplicated illness or injury
99214/99204 Moderate One or more chronic illnesses with exacerbation, progression, or side effects of treatment; or two or more stable, chronic illnesses; or one undiagnosed new problem with uncertain prognosis; or one acute illness with system symptoms; or one acute complicated injury
99215/99205 High One or more chronic illnesses with severe exacerbation, progression, or side effects of treatment; or one acute or chronic illness or injury that poses a threat to life or bodily function

Number of Diagnoses and/or Management Options

The number of possible diagnoses and/or the number of management options to consider is based on:
● The number and types of problems addressed during the encounter
● The complexity of establishing a diagnosis
● The management decisions made by the physician

In general, decision making for a diagnosed problem is easier than decision making for an identified but undiagnosed problem. The number and type of diagnosed tests performed may be an indicator of the number of possible diagnoses. Problems that are improving or resolving are less complex than those problems that are worsening or failing to change as expected. Another indicator of the complexity of diagnostic or management problems is the need to seek advice from other health care professionals.

Here are some important points to keep in mind when documenting the number of diagnoses or management options. You should document:

● An assessment, clinical impression, or diagnosis for each encounter, which may be explicitly stated or implied in documented decisions for management plans and/or further evaluation:
• For a presenting problem with an established diagnosis, the record should reflect whether the problem is:

• Improved, well controlled, resolving, or resolved
• Inadequately controlled, worsening, or failing to change as expected

• For a presenting problem without an established diagnosis, the assessment or clinical impression may be stated in the form of differential diagnoses or as a “possible,” “probable,” or
“rule out” diagnosis

● The initiation of, or changes in, treatment, which includes a wide range of management options such as patient instructions, nursing instructions, therapies, and medications

● If referrals are made, consultations requested, or advice sought, to whom or where the referral or consultation is made or from whom advice is requested

Amount and/or Complexity of Data to Be Reviewed

The amount and/or complexity of data to be reviewed is based on the types of diagnostic testing ordered or reviewed. Indications of the amount and/or complexity of data being reviewed include:

● A decision to obtain and review old medical records and/or obtain history from sources other than the patient (increases the amount and complexity of data to be reviewed)

● Discussion of contradictory or unexpected test results with the physician who performed or interpreted the test (indicates the complexity of data to be reviewed)

● The physician who ordered a test personally reviews the image, tracing, or specimen to supplement information from the physician who prepared the test report or interpretation (indicates the complexity of data to be reviewed)

Here are some important points to keep in mind when documenting amount and/or complexity of data to be reviewed. You should document:

● The type of service, if a diagnostic service is ordered, planned, scheduled, or performed at the time of the E/M encounter.

● The review of laboratory, radiology, and/or other diagnostic tests. A simple notation such as “WBC elevated” or “Chest x-ray unremarkable” is acceptable. Alternatively, document the review by initialing and dating the report that contains the test results.

● A decision to obtain old records or additional history from the family, caretaker, or other source to supplement information obtained from the patient.

● Relevant findings from the review of old records and/or the receipt of additional history from the family, caretaker, or other source to supplement information obtained from the patient. You should document that there is no relevant information beyond that already obtained, as appropriate. A notation of “Old records reviewed” or “Additional history obtained from family” without elaboration is not sufficient.

● Discussion about results of laboratory, radiology, or other diagnostic tests with the physician who performed or interpreted the study.

● The direct visualization and independent interpretation of an image, tracing, or specimen previously or subsequently interpreted by another physician.

Provider Documentation

When documenting the medical visit, physicians must ensure that the medical record documentation is:

1. Intelligible- The medial record should include the date and legible identity of the physician who furnished the service.
2. Concise- The care the patient received and related, facts, findings and observations about the patient’s health history.
3. Supports the medical necessity reason for the visit and the level of E&M service billed.
4. The medical record must be complete.

Medical Record Authentication

The health plan requires that services provided to the member must be authenticated by the author of the medical record. Medical records must be signed prior to submission of the claim.
The signature must be handwritten or electronically signed.

Providers who do not adhere to the requirements above, may experience a delay in claims payment, a disallowance of payment for a service or claims may be subject to a post payment
medical record review.