billing & coding

Level of Medical Decision-Making
The final installment of our E/M coding series deals with decision-making.

After determining the history and physical examination levels of the E/M visit (See OM January and March 2007), you are ready to determine the third key component: the level of medical decision-making. Decision- making refers to the complexity of establishing a diagnosis, as well as the complexity of treatment and management options. There are three main elements:
1. The number of diagnoses and management options
2. The amount and complexity of information reviewed, obtained and analyzed including: medical records, diagnostic tests and discussions with other physicians
3. The risk of complication, morbidity or mortality associated with the presenting problem, diagnostic procedures or possible management options.

Complexity of information
For a given level of decisionmaking, two of the three main elements from the table below must be met or exceeded. I have found that complexity of information is the most subjective element. Problems that are not improving or worsening are considered more complex than problems that are resolving. Also, discussions with other physicians or the need to refer would indicate a greater degree of complexity.
The medical record must clearly state whether the patient’s condition or conditions are improved, resolved, stable or worsening. All discussions and treatments must be documented. Treatments include a variety of options such as patient instructions, medications, therapies and surgery or referral decisions.
Base your risk assessment of the chief complaint on the anticipated risks between the current office visit and the next. Carefully consider and document associated diseases and other factors that might increase the risk of complications).
With this final installment of the E/M coding series, you can now create an E/M coding guide that works for you. More importantly, you have the right tools to accurately code E/M office visits.

DR. MACK IS DIRECTOR OF CLINICS AT THE OHIO STATE UNIVERSITY COLLEGE OF OPTOMETRY. SEND E-MAIL TO CMACK@OPTOMETRY.OSU.EDU