June 5, 20204 Volume 1, Issue 2

In 2021 & 2023, big changes were made by Center for Medicare & Medicaid Services (CMS), the goal being to help simplify professional billing documentation requirements. If you missed them, this was a big deal! You could be documenting extensive, excess information, which may lead to note bloat. It’s important to include evidentiary documentation in order to accurately support the MDM and level of professional coding you may be able to report.

Let’s get started!

Out with the old, in with the new!

The old guidelines determined Level of Service by a required compilation of chief complaint qualifiers, review of systems points, past medical/family/social histories, number of organ system and the physical exam, and MDM -or- face-to-face time with >50% spent counseling/coordinating.

The new documentation guidelines (2021 Office/Other Outpatient E&M (New/Est), 2023 Inpatient/Consultation) require:

1. A medically appropriate history of present illness (HPI)

2. A medically appropriate physical exam (PE)

3. Documentation of MDM -or- Total Time

That’s it. So much easier!  This now allows one to shift documenting focus to assessment and treatment.

MDM & essentials necessary for your documentation

While the MDM changes minimize billing requirements, they are not minimal documentation requirements.

You always need both a medically appropriate history and a physical exam in your documentation. This is necessary to describe how medical services provided are clinically indicated. This component of work may also support quality initiatives, for example medication reconciliation and immunization verification. 

The MDM table (pages 4-5) demonstrates components of each element and how to meet levels within that element. The MDM table elements are the same, whether you are conducting outpatient or inpatient medical care.

If your time to perform and complete a visit exceeds the threshold associated with your MDM level, use time, and be sure to document how you used your time.

Let’s dig into understanding nuances of the elements!  Tips and considerations on specifics within each element will be covered.

Number & complexity of problems address

· Any problem counted must have a component of “MEAT:” Monitoring, Evaluating, Assessing, or Treating. Listing problems does not mean that it automatically counts.

· “Stable” means at treatment goal. At a visit, you may decide not to make any treatment changes, however, if the patient is still working towards an unmet goal, that condition is not yet “stable.”

· Chronic illness is described as a condition which has either been ongoing for at least one year prior to the encounter, or a new condition which is expected to last more than one year the encounter.

· The final diagnosis does not alone determine the complexity or risk of the problem. Manifesting new symptoms that could represent a highly morbid condition may drive MDM, increasing the complexity of your evaluation.

Amount and/or complexity of data to be reviewed & analyzed

Category 1: Tests, documents or independent historian(s)

Lab panels and serial labs only count for order/review of 1 test

· A Basic Metabolic Panel counts as 1 test, not 8

· A batch of serially performed tests count as ordering 1 test

· In reviewing tests, be specific and comparative, include a diagnosis for linkage, e.g. “Hyponatremia, sNa 134 improved from sNa 129 yesterday

Document who is an independent historian & what information is provided.

· An independent historian provides a history in addition to one provided by a patient, who is unable to do so completely or reliably (because of developmental stage or loss of consciousness), or because of a confirmatory history that is judged to be necessary.

Category 2: Independent interpretation of tests

Your personal interpretation of a test or study should describe your assessment; it does not need to be a formal report when not separately reported.

Tests that do not require separate interpretation (e.g., tests that are results only) and are analyzed as part of MDM do not count as an independent interpretation, but may be counted as ordered or reviewed for selecting an MDM level.

Category 3: Discussion of management or test interpretation

“External” means the Qualified Health Providers (QHP) or appropriate source is outside your group practice or in a different specialty/subspecialty.

· Non-physician providers (NPPs) who work with physicians are in the same group or specialty/subspecialty as the physician.

· External communication may not be through intermediaries, e.g. office staff, trainees

· Discussion does not need to occur on the same day, however, should occur within 1-2 days

· A QHP performs and independently reports professional services

· You may not count discussions with nursing, social work, case managers, etc. who also work in your setting.

· You may count discussions with teachers, lawyers, parole officers, etc. as an “appropriate source” when they are involved in the treatment of the patient outside of your setting.

· Document about what & with whom you had external discussion(s).

· Sending medical record notes does not count as discussion.

Both independent interpretation AND discussion of the test results with the interpreting physician can be counted when both are performed for the same encounter.

Data Case Examples

A 12-year-old patient presents with right ear pain. Based on history and examination, right swimmer’s ear is diagnosed.
Data reviewed & analyzed -> Minimal or none

A 6-year-old patient presents with a thumb laceration. The patient’s mother explains concern that the bleeding did not stop until pressure was held for several minutes. After the laceration is evaluated, the wound is cleansed & bandaged.
Data reviewed & analyzed -> Limited  (An independent historian is required)

A 5-month-old infant is brought in for evaluation of difficulty breathing with URI symptoms. The parent provides the patient’s medical, family and social history. A respiratory viral panel, CBC and chest x-ray are ordered.
Data reviewed & analyzed -> Moderate (4 tests ordered, an independent historian is required)

A 9-year-old is brought in for evaluation of fever, cough and vomiting for 2 days. The parents provide a history of fever to max of 39C that started 1 day prior after 2 weeks of coughing, along with 2 days of vomiting. A chest x-ray and an influenza test is ordered. The pediatrician independently reviews the chest x-ray and provides his interpretation.
Data reviewed & analyzed -> Extensive (2 tests ordered, an independent historian is required, independent test interpretation)

Risk of complications and/or morbidity or mortality of patient management

The risk of a condition is distinct from the risk of managing the condition.

Prescription drug management does not require a prescription be ordered at the visit, however, the medication requires prescriptive authority. Thus, over the counter medications do not count.

· Include the name, dosage & frequency of the medication you are prescribing, along with how you are managing it (increase, decrease, continue) and WHY, along with the correlating diagnosis.

Example: “Continue albuterol 2 puffs with spacer q4-6h as needed for mild intermittent asthma that is well controlled”

If including Social Determinants of Health (SDoH), include the affected diagnosis and/or treatment and what SDoH is impacted and how.

· SDoH examples: food insecurity, housing insecurity, financial strain, transportation obstacles

Risk may include management options considered, but not selected, and decisions regarding minor and major surgery and risk factors that are related to the procedure when practicing shared decision-making with the patient and/or family.

Patient Management Case Examples

A 3-year-old presents for follow-up after a course of hand, foot & mouth. The patient appears well. The parents have no concerns, but need clearance to return to child care, which is provided.
Risk of patient management -> Minimal to none

A 4-year-old is brought in for 3 days of runny nose, watery eyes, & sneezing, but no fevers. After examination, daily as needed use of OTC allergy medication is recommended.
Risk of patient management -> Low

A 9-year-old is seen in the ED for right arm injury. A fracture is diagnosed by x-ray, and repair under general anesthesia is recommended. The parent agrees to proceed with the procedure.
Risk of patient management -> Moderate (Decision for major surgery)

A 14-year-old presents for follow-up of asthma. The patient’s asthma is well-controlled, and a refill of control medication is prescribed.
Risk of patient management -> Moderate (Prescription medication)

An 2-year-old patient has been observed for gastroenteritis management, and has persistent poor oral intake. After examination and data review, the hospitalist recommends inpatient hospitalization to manage of continuing symptoms.
Risk of patient management -> High (Decision to hospitalize)