Q&A: Medical decision-making considerations

Q: What are some tips for properly documenting evaluation and management (E/M) as it relates to medical decision-making (MDM), including improving communication with providers?

A: Here are some considerations:

MDM may be impacted by role and management responsibility. What does that mean? It means that the provider may only be focusing on one problem, but they talk about problems that are being taken care of by another provider or that the patient also has XYZ. Well, their MDM will impact those other conditions so they have to be actively involved in caring for those other conditions.

Any service reported with a separate CPT code that includes interpretation and/or report should not be counted in the MDM when selecting the level of service. If the provider is getting paid for any service separately beyond their E/M, don't count that service in the MDM elements or you will get paid twice for it. Every CPT code, every E/M code has a built-in component for the service, and you don't want to double count anything.

Shared MDM involves eliciting patient and/or family preferences, patient and/or family education, and explaining risks and benefits of management options. The provider is focusing not only on the patient but including the family and explaining those risks and benefits of management options.

Ask providers this: Consider what would happen to the patient if they left the appointment without any further work-up. When you're looking at the risk column in the E/M MDM table, that kind of helps put into perspective the severity level. Now, I'm saying this from a non-clinical standpoint; I am not clinical. I look at this from an E/M guidelines standpoint. If my provider tells me something clinically that can be substantiated in the documentation, I have no problem giving credit for something. A lot of times you may find that the provider thinks they've given themselves enough to support it, but after we've discussed it, it's more of [an opportunity to say], “The next time you document something like this, make sure you're including XYZ that you just told me about because without it, it won't support that visit.”

Editor’s note: This Q&A was originally published in JustCoding. Brenda Edwards, CC, CDEO, CPB, CPMA, CPC-I, CEMC, CRC, CPMS, CMRS, CMCS, CEMA, CPA-RA, CPA-EDU, provided this information in the webinar, “Avoid E/M Blunder Areas: Boost Your MDM Game, Communicate Effectively.”