- D: all of the above. Medical decision making is made up of three components:
- Number of diagnoses or treatment options;
- Amount and/or complexity to be reviewed; and
- The risk of complications and/or treatment options
.
There are four levels of risk and within each level and three sections to choose the type of complication, e.g., present problems, diagnostic procedures ordered, or management options. Prescription drug management is considered to be a moderate level of risk under the management options. The level of risk for a patient requiring monitoring for toxicity is high. Lastly, if the patient’s chart is documented reflecting severe exacerbation of one or more chronic illness, such as rheumatoid arthritis, the level of risk for this patient would be considered to be high under the presenting problem section.
- C: Three vital signs must be documented in the patient chart to get credit for examining the constitutional system. There are seven vitals to choose from:
- Sitting or standing blood pressure
- Supine blood pressure
- Pulse rate and regularity
- Respirations
- Temperature
- Height
- Weight
- B: No. While it is true that you only need two out of the three components—history, examination, and medical decision making (MDM)—to be comprehensive, one must be MDM. Every service that is provided to a patient is based on medical necessity. MDM is the driving force when determining medical necessity and, thus, drives the level of history and examination.
- D: Both A and B. The Centers for Medicare and Medicaid Services created the evaluation and management documentation guidelines. CMS determined the 1995 documentation guidelines to be too ambivalent. Therefore, CMS developed more detailed requirements for part of the history component and the entire examination component in the 1997 version. The difference for the history is in the History of Present Illness (HPI). For 1995, the HPI requirement is to document up to four elements out of eight:
-
Location—Where on the body is the problem?
Duration—How long has the problem been there?
Severity—How would you rate the pain on a scale?
Quality—What is the symptom like (e.g., sharp, dull)?
Context—How did symptom start?
Modifying factors—What make it better?
Associated signs and symptoms—Are there any other signs or symptoms, other than the main problem?
Timing—When do the symptoms occur?
While both versions require documentation of the exam for both organ systems and body areas, the 1995 version allows the physician to decide how much to review of each area of the exam. The 1997 version requires specific documentation guidelines for each body area, which are detailed by bullets, and each bullet has very specific requirements that must be met in order to receive credit for the examination of that body area. For example if a physician does a musculoskeletal exam, four of the following six body areas must be examined to meet the requirements of that organ system:
- Head and neck
- Spine, ribs, and pelvis
- Right upper extremity
- Left upper extremity
- Right lower extremity
- Left lower extremity
Even though the physician is choosing to perform a musculoskeletal exam, documentation guidelines require the health professional to also examine and document the constitutional, cardiovascular, lymphatic, skin, and neurological/psychiatric systems.
Didn’t do so well on the quiz? Don’t feel bad—understanding the E/M documentation guidelines is a complicated process and sometimes causes confusion even among seasoned coders. To see the full description of both the 1995 and 1997 documentation guidelines visit, www.cms.gov under evaluation and examination. For rheumatology-specific coding information, download your free copy of the ACR’s Rheumatology Coding Manual. Visit www.rheumatology.org/publications and click on “Practice Management Publications” to get your copy.
If you have questions or need more information on the auditing process, contact Melesia Tillman, CPC-I, CRHC, CHA, at (404) 633-3777 ext. 820 or [email protected].
