Focus on E/M services: MDM first element

November 6th, 2020 / By Rebecca Caux-Harry

In this next blog post in our blog series focused on the new E/M guidelines, I’m going to focus on Medical Decision Making, which along with Time, is a key determinant of the level of care we report for reimbursement starting in 2021. MDM continues to be broken into three elements, the first of which is Number and Complexity of Problems Addressed. This is a familiar concept but deserves to be revisited for clarity. We’ll address the remaining two elements and the concept of Time in the next blogs in our series.

MDM Element: Number and Complexity of Problems Addressed

How are problems defined in the new guidelines? Per the AMA guidelines “a problem is a disease, condition, illness, injury, symptom, sign, finding, complaint or other matter addressed at the encounter, with or without a diagnosis being established at the time of the encounter.”

But the guidelines state “Problems Addressed.” This means that the problem must be evaluated or treated at the encounter by the provider, not simply mentioned in a problem list or stated as being managed by another provider. Evaluation and/or treatment might include modification of medications, ordering additional testing or simply evaluating the status of the problem as it is currently being treated and opting to continue with the current treatment. 

Next, determine the complexity of the present problems being treated. The categories remain mostly unchanged from the table of risk currently used. They are:

Minor = This type of problem doesn’t normally require the presence of a physician. An example might be a weight or blood pressure check with no intervention.

Self-limited = This is a problem that without intervention should resolve on its own. An example of a self-limited problem would be a cold in a patient without comorbidities.

Stable, chronic illness = This is a problem with a duration of at least one year that is maintained at the treatment goals for the individual. This might be a patient with well-managed non-insulin dependent diabetes or hypertension.

Acute, uncomplicated illness or injury = This is a new or recent short-term problem with low risk of morbidity. A patient with a sprain or allergies would be an example.

Chronic illness with exacerbation, progression, or side effects of treatment = This is a worsening or poorly controlled chronic illness which will require additional care or adjustments to care, or one which creates side effects as a result of care. Examples of this type of problem would be uncontrolled or poorly controlled hypertension or diabetes that now needs insulin.

Undiagnosed new problem with uncertain prognosis = This is a patient who presents with symptoms, but no definitive diagnosis can be made during the visit. Usually testing is needed to make the final determination. A lump that might be cancer, or severe abdominal pain would fall into this category.

Acute illness with systemic symptoms = This is an illness with high risk of morbidity without treatment. Systemic symptoms could be high fever and/or vomiting. An example could be pneumonitis.

Acute, complicated injury = This is an injury that would require a broader exam than just the injured body part, where treatment options would have an associated risk. A closed head injury with brief loss of consciousness is a common example of this type of injury.

Chronic illness with severe exacerbation, progression, or side effects of treatment = This type of problem usually requires hospital care due to the severe exacerbation of the illness. A patient with congestive heart failure with severe shortness of breath and swelling in the extremities is an example.

And lastly,

Acute or chronic illness or injury that poses a threat to life or bodily function = This is a problem that requires hospital care, without which the patient would likely expire. Examples would be an acute MI, pulmonary embolism, COVID-19 with severe shortness of breath and chest pain, auto injury that poses a threat to life or bodily function without hospitalization.

For those experienced with E/M coding, these problem elements will be familiar: Our job will be to review the documentation and categorize the problems addressed during the encounter to start to build the level of care based on Medical Decision Making according to the new guidelines. Watch for our next blog in this E/M series, which will post soon. It will outline the extensive changes to the second element of MDM: “Amount and complexity of data to be reviewed and analyzed.”   

Rebecca Caux-Harry, CPC, is a professional fee coding specialist with 3M Health Information Systems.

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