How Well Can You Score MDM?

I had the great pleasure of speaking in Denver, CO last week and our discussion came to the topic of medical decision making (MDM) and how that relates to the overall level of an evaluation and management (E/M) codes. Specifically, I made the point that I would be hard pressed (but I can think of some) to think of an ocular condition that carried a minimal level of risk (self limited or minor).

This naturally turned the conversation to a subconjunctival hemorrhage, as is typically the case, and the contention that it should be billed as a 99212. More on this below.

Why is MDM important?

We are seeing CMS moving towards initiatives that focus on patients over paperwork and in this push we will see a greater focus on MDM for the E/M coding levels. This movement will push us to me more accurate and pay better attention to the level of our MDM. Additionally, in my experience consulting with optometric practices, this is one area that ODs chronically underestimate the value of their services. This underestimation can easily cost a practice tens of thousands of dollars annually.

So what about a subconjunctival hemorrhage?

When we look at MDM there are 3 areas to score (we use the highest 2):

  1. Number of Diagnosis and Treatment Options

  1. Complexity of Data

  1. Risk

It is easy to see that when we score the number of diagnosis and treatment options, if a patient presents with a new subconjunctival hemorrhage that would be considered a new condition without work up (assuming we didn't order any additional tests) which would give us multiple (3) diagnosis and treatment options.

If we didn't order any additional tests, then the complexity of data reviewed/ordered would be considered minimal (0 or 1 test ordered).

Even if we classify the type of problem as self limited or minor, if we look at the common treatment (artificial tears) we see that the treatment would be considered low risk.

The overall MDM scoring of this case would lead us to a 99213 assuming the patient was established and we documented either an:

  • Expanded Problem Focused History

  • 1-3 HPI

  • 1 ROS

  • Expanded Problem Focused Examination

  • 6-8 elements of an exam

This is a classic example (but only one of many) of how we commonly underestimate the value of our services. If you are ready to protect yourself in an audit AND generate a more appropriate revenue for the services you spent so much time and money perfecting, click below to enroll in our comprehensive billing and coding program for your entire office: