To identify the suitable level of an E/M service, the documentation needs to meet or exceed two out of three components – Problem, Data, and Risk. The American Medical Association (AMA) has published a resource, Table 2 – CPT E/M Office Revisions Level of Medical Decision Making (MDM), on their website, which can be referred to as a guide for determining the appropriate E/M code based on MDM. It is crucial to associate the code selection with the criteria specified for each level and code.
This edition focuses on risk, the third element of medical decision-making (MDM).
Element 3
Risk of Complications and/or Morbidity or Mortality of Patient Management: The risk of complications and/or morbidity in this section of the MDM relates directly to the risk associated with appropriate treatment rather than the treatment itself.
Clarifying “Risk” Definitions: Each level of MDM is associated with a level of risk of morbidity from additional diagnostic testing or treatment, as outlined in the MDM table. A frequent assumption regarding patients with cancer is whether undergoing chemotherapy (“Drug therapy requiring intensive monitoring for toxicity”) is automatically considered “high-risk”. However, that is not always the case.
Monitoring is included in the MDM when it is considered part of the management of the patient. Putting it all together: After the level of each of the categories is determined, the level of service for the evaluation and management code can be determined. Again, two of the three elements must be met or exceeded to report the applicable E/M code.
- Comorbidities and underlying diseases are not considered in selecting a level of E/M service unless they are addressed as part of the service. Their presence increases the amount of data to be reviewed/analyzed or the risk of patient management complications/or morbidity, or mortality.
- The final diagnosis of a condition does not necessarily determine the complexity or risk. Presenting symptoms that represent a highly morbid condition may require extensive evaluation to determine the ultimate diagnosis.
American Medical Association. “2023 Evaluation and Management (E/M) Code and Guideline Changes”. 2022. 2023 CPT E/M descriptors and guidelines
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Nancy Entwistle MPA, RHIT, CCS, CANPC, CCDS AHIMA Approved ICD10-CM/PCS Trainer EVP, Regulatory Coding Compliance n.entwistle@calmwatersai.com |