Key components of evaluation and management: Medical decision making
Cracking the Code
Dr. Miller, who is in private practice in Yorba Linda, California, represents the American Academy of Dermatology on the AMA-CPT Advisory Committee.
By Alexander Miller, MD, August 1, 2018
Medical decision making (MDM) is the third key component of evaluation and management (E/M) that is used for defining levels of service. It is also more challenging to quantify than the first two: history and physical examination. Medical decision making is stratified in the Current Procedural Terminology® (CPT®) manual into four categories: straightforward, low complexity, moderate complexity, and high complexity.
The degree of complexity is determined by three elements:
- Number of diagnoses considered or management options
- Amount and/or complexity of data to be reviewed, including medical records and diagnostic tests
- Risk of significant complications, morbidity, and/or mortality; comorbidities, only if these significantly increase medical decision making complexity
To qualify for a specific level of medical decision making, components of at least two elements must meet or surpass the criteria listed for that level of service. See Table 1, below.
CPT does not explicitly define the meanings of the various strata of complexity, such as “minimal,” “limited,” etc. It is up to the individual practitioner, biller, or coder to figure this out and integrate it into determining a proper level of E/M service. Attempts at quantifying decision making by assigning numerical values to various chart data sets are aimed at bringing objectivity to the process. The Centers for Medicare and Medicaid Services (CMS) provides greater detail in a Medicare Learning Network (MLN) publication dated August 2017. These criteria are likely to be used by Medicare auditors ferreting out chart data to determine a level of medical decision making.
Below is an abridged version of CMS criteria for each of the three decision making components.
Number of diagnoses and/or management options include:
- Number and types of problems dealt with during the visit
> Decision making for problems you (or another dermatologist in your practice) previously diagnosed may be simpler than for specified but not precisely diagnosed problems
- Complexity in establishing a diagnosis
> Requiring an opinion from another health care professional may indicate greater complexity
- Types of management decisions made
> Improving/resolving problems are judged to be less complex than those worsening or failing to improve
One should document pertinent diagnoses/management options, including:
- Assessment/diagnosis
- Improvement, stability, or resolution of a problem; may document whether expectations for treatment results are met
- Include differential diagnoses when pertinent
- Describe management components, including patient instructions, medication risks/benefits
Risk of complications, morbidity, mortality
- Risk is determined for each of the following categories:
> Presenting problem
> Recommended diagnostic procedures
> Treatment options
- Risk is assessed between the existing encounter and the next anticipated patient encounter
- Level of risk (minimal, low, moderate, high) is determined by the highest risk level within any one of the above three categories
Document the following:
- Comorbidities/associated diseases that increase risk of complications, morbidity, mortality
- Type of diagnostic or surgical procedure scheduled as a consequence of the E/M evaluation
- Any procedure done during the course of the E/M
- Urgent referral for diagnostic or surgical procedure
Table 2 provides a stratification of risk and includes some dermatology-specific examples.
The third component of MDM, amount and complexity of data to be reviewed, is rarely crucial to determining MDM levels in dermatology. However, there are instances where extensive laboratory/pathology reports review or detailed examination of outside chart material is done. In such situations this component of MDM may be relevant. In most cases diagnoses and management options and the risk of significant complications, morbidity, and/or mortality categories will be used for determining MDM. Only two of the three components of MDM must be graded to establish an MDM level. So, scoring low on the data review category is typically not relevant.
The CPT describes an additional, useful component for determining E/M levels: Nature of Presenting Problem. This is a reason for an encounter that is classified as minimal, self-limited or minor, low severity, moderate severity, and high severity. The exact descriptions of each encounter category are found in the Evaluation and Management (E/M) Services Guidelines section of the CPT.
What if greater than 50% of a patient visit is spent on face-to-face counseling and/or coordination of care rather than history, examination, and MDM? Then, time will determine a level of E/M service.
For time-based services one should document the following:
- Counseling and/or coordination of care encompassed greater than 50% of face-to-face encounter time
- Total length of time of encounter
- The counseling and/or coordination of care provided
Next month’s Cracking the Code will bring the key components of E/M together to illustrate various encounter scenarios and their corresponding E/M levels.
