This is the last part of our review of Evaluation and Management (E&M) coding. We need to cover medical decision making (MDM), the rules on the key element inclusion and suggestions on coding strategies. In review, there are three key elements; History, Physical Exam and Medical Decision Making (MDM). We have covered the History and Physical Exam requirements in the last two newsletters. MDM has three sections; radiographs/data, diagnosis/impression and plan/risk. The 1997 Guidelines and the Center for Medicare and Medicaid Services (CMS) allows points for certain bullets in each section. For simplification the abbreviations are as follows; (new patients = N, established patients = E, and the level of service is noted by 3 or 4)
A. Radiographs/Data – N3 and E3 requires 2 pts, E4 requires 3 pts
a. Radiographic interpretation (2 pts)
b. Reading the radiographic or test report (1 pt)
c. Review the chart (2 pts)
d. Request a radiograph/test/chart (1 pt)
e. Contact the primary care or referring physician (1pt)
B. Diagnosis/Impression – N3 and E3 requires 2 pts, E4 requires 3 pts
a. Known diagnosis stable or improved (1 pt)
b. Known diagnosis worsened (2 pts)
c. New diagnosis – work-up not required (3 pts)
d. New diagnosis – work-up required (4 pts)
C. Plan/Risk
a. N3 or E3 requires documentation of;
i. Plan
1. Over the counter medication
2. PT/OT
3. Minor surgery w/o risk
ii. Risk
1. Baseline is an uncomplicated ankle sprain
2. An injury of this severity or greater = N3 or E3
b. N4 or E4 requires documentation of;
i. Plan
1. Prescription medication
2. Minor surgery with risk factors – joint injection
3. Major surgery
ii. Risk
1. One complicated injury or condition of greater severity than an uncomplicated ankle sprain
2. Two or greater stable diagnoses
3. Non or manipulative fracture care
The difficulty with MDM arises from the apparent "complicated" rules determining the level of service. Let us clarify the rules and make MDM as easy as the history and physical.
1. For audit purposes, a patient’s medical record needs 2 of 3 parts of the MDM but one section must be the plan/risk. The physician must provide a complete medical record but when a chart is audited for correct coding only the following are required. Radiographs/data or diagnosis (s)/impression must accompany the risk/plan. The rationale being that it is the risk/plan that the payor wants and needs from the physician.
2. Let us break down patient visits and the rationale of coding.
a. A patient presents with an uncomplicated ankle sprain.
i. A level 5 history is always obtained with the new patient history form
(Part as a set available from AANA for $750.00).
ii. The physical exam includes examination of two extremities and includes 12 bullets = new level
3 physical exam.
iii. For the MDM key component, an x-ray is obtained and interpreted (2 pts), the diagnosis is an acute
traumatic ankle sprain (2 pts) and the risk for an ankle sprain is the baseline for a new level 3 service.
iv. The documentation of all three sections of the MDM should be included in the medical record but
for an audit only the data or the diagnosis section was necessary along with the plan. This is a classic
99203 visit; level 3 (level 5 history, level 3 physical and a level 3 MDM). The payment/service level
is based on the lowest level of the required three key components = level 3 or 99203.
3. Before we discuss a return visit or an established patient visit there is one byte of information that will make your job easier. The 1997 E&M Guidelines and CMS have given the physicians a "break" in the information required for documentation of Established patient visits. Only 2 or 3 of the Key Components must be documented for Established patient visits but one of the Key Components documented must be the MDM. So for audit purposes, only the history or the physical exam is subject to an audit for established patients! Thus you now understand the infamous 2 of 3 rule for Established patients (we’ve already reviewed the 2 of 3 rule for MDM)
a. This same patient returns in two weeks for a follow-up appointment.
i. A level 5 history is obtained with the follow-up patient questionnaire which updates any new findings
and references the majority of the history from the initial visit.
ii. The physical exam is performed and documented with a minimum of 12 bullets and 2 body parts for
a level 3 visit.
iii. For audit purposes only one of these two key components must be reviewed.
iv. For the MDM, if the radiograph is repeated or any other data is reviewed then the 2 pt requirement
is met. Since the plan/risk of an ankle sprain is sufficient or if PT/OT or over the counter pain
medicine is prescribed then the requirements for a level 3 visit where met.
v. Coding = 99213
b. An established patient (a patient that has been seen in your practice in the last three years) presents with
an un complicated ankle sprain, diabetes and cellulitis.
i. A level 5 history is obtained for this new problem in an established patient.
ii. A physical examination is performed comparing the injured and uninjured body parts (12 bullets) =
N3 or E4
iii. The MDM qualifies for a level E4 visit because;
1. With more than one diagnosis (ankle sprain, cellulitis, and diabetes) the diagnosis and impression
section is met. New diagnoses give 2 pts. for each = 6 pts and only 3 pts. are required.
2. The plan and risk section are easily met by the fact that the risk sufficient for an E4 patient
(complicated injury) and two stable diagnoses (cellulitis and diabetes). In addition if the patient
requires antibiotics or prescription medications the risk is again sufficient for an E4.
iv. So the history is a E5, from an audit standpoint we will pass on the physical exam and the MDM is
an E4. So the visit qualifies as an 99214.
In conclusion, hopefully AANA members will take the last three newsletters and review the Key Components and the coding requirements. We should approach E&M coding with the following rationale; the standard new orthopaedic visit is a N3 (99203). Established patients that have a single diagnosis are routinely E3 (99213). Established patients with more than one diagnosis or more severe diagnosis(es) requiring invasive treatment or prescription medications are E4 visits (99214). Documentation supporting the level of service is mandatory. It is very important that physicians spend the time and energy learning and practicing correct E&M coding. The penalties for fraudulent coding, whether intentional or unintentional, are severe ($10,000 fine per occurrence and 5 years in jail).
