Diabetes patients can present podiatrists with some of their most complex cases and if you don’t evaluate the level of medical decision-making your podiatrist performs for such patients, you can be at risk of undercoding the services—and losing out on money.
Although diabetes patients are regular fixtures in podiatry practices, many podiatry coders inappropriately code the correct E/M level for these visits because they don’t properly evaluate the level of medical decision-making these more medically complex patients require.
The problem: Assessing the history and exam components of an E/M is fairly straightforward, but medical decision-making (MDM) is complex—requiring you to asses three separate categories:
- number of diagnoses/management options (minimal, limited, multiple, extensive)
- amount and complexity of data (minimal, limited, moderate, extensive)
- level of risk (minimal, low, moderate, high).
To determine the level of risk, you must also assess three subcategories:
- presenting problem
- diagnostic procedures ordered
- management options.
Many podiatry coders slip up on MDM and downcode their claims resultantly.
The solution: Follow these steps to properly assess a visit’s level of MDM and ensure your DPM’s E/M code levels are appropriate.
To determine the level of MDM, you should assign points to each of the three MDM components that your podiatrist performs. The number of points in each category determines the final MDM level. You must have two out of the three MDM components score at a particular level in order to assign that level of MDM. For example, if the number of diagnoses is low, but the amount and complexity of data and level of risk are both moderate, your MDM score is moderate.
Use this overall MDM scoring scale to determine MDM level:
- 2-3 “minimal” components: straightforward decision-making
- 2-3 “limited” components: low decision-making
- 2-3 “moderate” components: moderate decision-making
- 2-3 “extensive” components: complex decision-making.
1. Learn Each Level of Diagnosis
Start your MDM level assessment by tackling the first category: number of diagnoses. For this category, ask, “What is wrong with the patient?” and “What is the total number of medical diagnoses that he has?”
Example: A diabetic patient with hypertension comes in complaining of toe pain. She has three diagnoses: the chief complaint of toe pain (729.5, Pain in limb), diabetes (250.xx) and hypertension (405.99).
Score: For each diagnosis, assign a point and score the diagnosis level as follows: minimal (0-1), low (2), moderate (3), high (4+). So in this case, with three diagnoses, you assign “moderate” as the diagnosis level.
2. Classify Your Data Complexity
Score the complexity of data in the same manner: minimal (0-1), low (2), moderate (3), and high (4+). Assign one point per class of data.
This means no matter how many X-rays or labs the podiatrist orders, you can only assign one point for ordering and reviewing all of the data in each of those two classes.
The classes of data you should consider are:
- Review/order of clinical labs
- Review/order of radiology
- Discuss results with test-performing physician
- Independent review of image, tracing or specimen
- Decision to obtain old records/ obtain history from someone other than patient
- Review and summarize old patient records
The podiatrist reviewing X-rays and MRIs, and calling the patient’s vascular doctor or the radiologist who reviewed the MRI – all of those bump up the level and the complexity of the data.
Example: A 14-year-old patient on vacation presents with an infected cut on the plantar surface of his foot that he sustained when he slipped and landed on jagged shore rocks at the beach. He also complains of severe pain in a different region from the laceration. The podiatrist orders blood work and X-rays and calls the patient’s primary physician for a complete medical history.
Score: Three points. You should assign one point for ordering and reviewing the lab work, one point for ordering and reviewing X-rays, and one point for obtaining the patient’s medical history from his primary physician. The level of amount and complexity of data is therefore “moderate.”
3. Examine the Risk
The final of the three MDM categories, level of risk, can be the most difficult part to determine.
Level of risk involves three subcategories: presenting problem, diagnostic procedures ordered, and management options. The highest scoring of the three categories determines if the patient’s risk level is minimal, low, moderate, or high. The Centers for Medicare and Medicaid Services’ 1995 guidelines for MDM contain a “Table of Risk” with examples of what constitutes each level of the three subcategories.
4. Change the Charge With MDM
To see how MDM level can affect E/M level, study these two examples of podiatry’s most frequently billed office visits – 99212 and 99213 (Office or other outpatient visit for the evaluation and management of an established patient …).
Example: A 16-year-old established patient complains of pain in her right hallux valgus. The pain is constant and throbbing, and has been for three days. The podiatrist reviews her skin and musculoskeletal systems, and performs a dermatological exam of the toe, diagnosing the patient with an ingrown toenail that will require surgery.
Breakdown: The medical decision-making here is straightforward. You have one diagnosis: an ingrown toenail. This means the level for number of diagnoses is “minimal.” The podiatrist wouldn’t order any labs in this case unless the toe is infected, in which case he would order blood work to check the patient’s white blood cell count. You should therefore assign either “0″ or “1″ for the amount and complexity of the data, which gives you a data level of “minimal.”
For level of risk is one self-limited problem, which qualifies as “minimal.” If the podiatrist ordered blood work, the ordered diagnostic procedure (venipuncture) also scores as “minimal.” And the management options are “low” because the patient requires minor surgery with no risk. The highest scoring component within this level of risk assessment is “low,” therefore the overall level or risk is “low.”
Final MDM: With two of the three MDM components scoring “minimal,” you have straightforward MDM. If we assume that the history and exam are problem-focused, and therefore also “minimal,” you should assign an E/M level of 99212.
Example #2: Consider the same scenario as above, but the patient is a diabetic on Coumadin, and the ingrown toenail is infected and draining a clear fluid. The podiatrist performs both dermatological and musculoskeletal exams, prescribes antibiotics for the infection, and arranges to see the patient again in five days to evaluate her for surgery.
Here, the patient has a low number of diagnosis and management options (diabetes and ingrown toenail), minimal data (clinical labs on diabetes and white count), but a low level of risk. In terms of management options, the surgery is minor, with added risk factors because of the diabetes and Coumadin, and the prescription drug management. These factors raise the level of risk to “moderate.”
Final MDM: You would assign this visit with low MDM level, along with an extended problem- focused exam (2-7 systems examined). Because established patients only require two of the three components, the MDM helps raise the E/M to a 99213.
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