Medical Decision Making – Breaking It Down. Part 1 of 3: Number of Diagnosis & Management Options

Medical Decision Making (MDM) is one of the three “key components” of determining the level of an evaluation and management (E/M) service. It is probably the most difficult component of an E/M service to review. MDM is where the providers thought process is quantified and most often the primary role in determining the correct level of service or E/M code.

It is important to note that both 1995 and 1997 Guidelines are the same with regards to MDM. According to the documentation guidelines, MDM is broken down and divided into three areas: number of diagnoses and management options, amount and complexity of data reviewed, and risk of complications, morbidity or mortality. Levels of MDM are Straightforward, Low Complexity, Moderate Complexity, and High Complexity. What makes it difficult is that we have not been provided much guidance as to how to identify the different elements or what makes up the difference between each level. Another thing that makes it hard to decipher is that to arrive at a particular level, you have to consider three tables, and within the table of risk there are three sections within it.

Remember, MDM is determined by the highest two of these three areas. In other words, one element does not equal your level of medical decision making. Often times, providers base their code selection solely on the risk of complications, forgetting the other two elements also play a role in determining the level of medical decision making.

NUMBER OF DIAGNOSIS or MANAGEMENT OPTIONS:

The number of possible diagnosis and/or the number of management options that must be considered is based on the number of types of problems addressed during the encounter, the complexity of establishing a diagnosis, and the management decisions that are made by the physician. Documentation: For each visit, an assessment, clinical impression, or diagnosis should be documented which may be explicitly stated or implied in documented decisions regarding management plans and/or further evaluation.

What problems or diagnoses (that require active management) are being evaluated, treated, or ruled out? If the notes indicate that you’re dealing with a self-limited problem that doesn’t require treatment, and you had no management options to worry about will have an impact on the level of decision making. What problems or diagnoses affect treatment? Is the problem an established problem or a new problem to the patient and/or provider? If the problem is an established problem, is it stable/improved or not controlled/worsening?

What type of treatments are being used, considered, or planned? Treatment includes a wide range of management options such as patient instructions, nursing instructions, therapies, and medications.

The guidelines also state that if, “referrals are made, consultations requested or advice sought, the record should indicate to whom or where the referral or consultation is made or from whom the advice is requested.”

Quantifying: Under the number of diagnosis and management options, there are three types of presenting problems (self-limited or minor, established, and new) that have been identified, with a total of five different categories.

The maximum number of points needed to reach the highest level of complexity is four.

Self-limited or Minor – is defined 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.

• Self-limited or minor problems can account for no more than two points, regardless of the number of self-limited problems the patient presents with.

Established Problem – these can be Stable/Improved or Worsening/Inadequately Controlled. These are the problems that you have already diagnosed and have started treating. 

• 1 point is assigned for each stable problem addressed during the visit, while 2 points are given for each worsening problem. (Note: check with your local carriers to determine whether or not a maximum number of points are imposed for established problems.)

• 3 points maximum are allowed for a new problem with no additional work up planned and 4 points for a new problem with additional work up.

 Written by: Gina Hobert, MBA, CHC, CPC-I, CECM, CMOM