The new E&M video is fantastic for determining the level of MDM. Itís described very well

so I just want to give a shout out for that.

Laureen: Yeah, thatís the CEU Webinar that sheís talking about thatís pending getting

CEU approval. But in the Blitz videos, I do cover E&M coding but because itís 2 days

where Iím doing this review Blitz and E&M codes are only 10 of the 150 questions on

the exam, I canít spend as much time as I would like to teaching it. So on the CEU one,

itís 3 hours. Itís more expanded and Alicia wrote the CEU quiz for me. So she had her

students watch it and I guess it was helpful so thatís good.

Alright, so where Iím going is in your CPT manuals, there is a Medical Decision Making

table in your E&M guidelines. And it happens to be on page 10. And of course, this is just

1/3 of the E&M you know, when youíre coding by the history exam and Medical Decision Making.

And as you can see, I like to mark things up and make it more visual. I actually drew

a line and made them look like columns because thatís what they are. To the far right is

the score, if you will, or the level of Medical Decision Making.

So youíve got straight-forward, low, moderate, and high. The first column is what I call

DMO for number of diagnoses or management options. And then choices you have are minimal,

limited, multiple, extensive. And Medical Decision Making is one of the most nebulous

areas of E&M to try and score. And youíve probably seen E&M scoresheets that they and

help quantify these things. But for purposes of the board exam, youíre not bringing in

an audit tool so you are going to have to use this language ñ minimal, limited, multiple,

extensive. Like for me, okay, Iím like, ìminimal versus limitedî. They sound pretty similar

to me so what youíll typically find is they count 1, 2, 3, 4. Itís for one diagnosis

for management option, limited is for two, etcetera.

For the second column, data, itís amount and or complexity of data to be reviewed.

So the types are minimal or none, limited, moderate, extensive. So those are the choices

there. When theyíre talking about data, it could be them reviewing an x-ray or reviewing

reports from a test that was run or lab results. Anything like that is reviewing of data. Again,

on those score sheets for Medical Decision Making, theyíve got this whole little point

system on how they add it up. You know, was the test in the radiology section? Was it

test from the lab section? And they kind of come up with a scoring system to figure out

if itís minimal, limited, moderate or extensive. On the board exam, they tend to give you the

words, the language to plugin.

The 3rd column is risk. Risk of complications and or morbidity or mortality. So thereís

minimal, low, moderate, or high risk and there is a table of risk that if you Google it,

you know, E&M Table of Risk. Itís on the CMS website. It is a set table and it will

have a bunch of things listed. Like for example, prescription meds. If a prescription is given,

itís automatically a moderate risk, if the physician wrote a prescription. Minimal would

be something like go home and gargle or rest, that kind of thing. So you get the idea. High

would be like theyíre recommending elective surgery or something like that.

So what you do is once you have the words or the levels of DMO, data and risk, we need

to do our leveling for 2 of 3. Because when you read the guidelines up above what Iíve

highlighted here, it says, ìTo qualify for a given type of decision making, 2 of 3 elements

in table 1Öî which is what weíre looking atÖ ìmust be met or exceeded.î So letís

see how that shakes out.

If you have aÖ let me move this over a little bit. Letís say, a multiple for DMO, a limited

for data, and a moderate for risk. So, multiple which shows up on the moderate level of complexity,

limited which shows up on the low level and moderate, which shows up on the moderate level.

So basically, a moderate, low, moderate. We can throw out the lowest. When itís 2 of

3, throw out the lowest code to the next lowest. So weíre going to throw out the limited or

the low complexity and that leaves us with moderate complexity Medical Decision Making.

So thatís how you could you know, do that on the board exam.

If you had aÖ letís just say, a limited high which translates to a low, low, high,

we can throw out one of the lows but the next lowest remains a low so itís low complexity.

So we can throw out one but not two. And thatís how 2 of 3 you know, leveling works. It works

in the Medical Decision Making table and it works with the overall E&M level scoring.

So thatís Medical Decision Making in a nutshell there. Thereís more information in your guidelines.

So you can see here, determine the complexity of Medical Decision Making and these bullets

correspond to those 3 columns that we were just looking at.

So DMO is the number of possible diagnoses with the number of management options that

must be considered. And remember, Medical Decision Making is whatís going in the physicianís

head toÖ after theyíve already taken your history, theyíve talked about review of systems,

theyíve done an exam based on that. Now, theyíre going to put it all together and

decide what to do about it. Are they going to send you for physical therapy? Are they

going to order tests? Is he going to write a prescription? Okay?

Data is the amount and or complexity of medical records, tests, or other information that

must be obtained, reviewed, and analyzed. So it could be obtained. They might write

an order for an x-ray. Thatís data. Or they might review an x-ray in a subsequent visit.

Thatís data, okay. Youíll also hear sometimes with phone calls, when a physician will talk

to a patient on the phone. If they document that phone call, they canít get credit for

it that day. But when they come back for the next visit, if they review that phone call

conversation, that can count toward data.

And then this third one, risk. The risk of significant complications, morbidity and or

mortality, as well as co-morbidities associated with the patientís presenting problems, the

diagnostic procedures and or the possible management options. And some of it seems a

little duplicative when you look at the Table of Risk and itís like, ìWell, itís talking

about diagnoses. Isnít that in the DMO, the number of diagnoses and management options?î

And yes, it is. But when you start breaking it down and doing it often enough, it makes

sense.

But keep in mind, for the board exam, youíre not going to need to know how to do it from

like an auditorís perspective. Now if youíre going for the E&M specialty credential, they

let you bring in an audit tool. And I share a really good one on the E&M you know, webinar

that you can use in your day to day coding. Itís actually modified from a Medicare webinar

I went to years ago. But itís all in one page which is kind of nice.

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