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Don't Underestimate Level of Risk in Your MDM

Warning: You may be downcoding E/M visits and losing deserved payment
Moderate-complexity medical decision-making may be all that stands between you and the added reimbursement that comes with a level-four E/M visit. Are your physicians shortchanging your practice?

A level-four new patient visit (99204), established patient visit (99214), and office consultation (99244) all require moderate-complexity medical decision-making (MDM) - something that endocrinologists are often wary to report.

Because many patients present such complicated cases, endocrinologists frequently manage internal medicine problems in addition to endocrine-specific conditions, says Curtis J. Udell, CPAR, CPC, CMPA, senior advisor at Health Care Advisors Inc. in Annandale, Va. Endocrinologists perform more E/M services than anything else, and they "cheat themselves every visit" when they don't report a level of service that fully reflects the extent of their medical decision-making and care plan management, he adds.

Improve your documentation: Downcoding essentially stems from omissions in the physician's documentation, Udell says. The first step to ensuring the correct level E/M, therefore, is to ask physicians for more complete documentation of all the factors he considers when choosing a plan of care.
Know the MDM Basics
CPT lists four types of MDM: straightforward, low complexity, moderate complexity, and high complexity.

Consider these three criteria to determine the MDM complexity:


the number of possible diagnoses and/or the number of management options the physician must consider


the amount and/or complexity of medical records, diagnostic tests, and/or other information the physician must obtain, review and analyze


the risk of significant complications, morbidity, and/or mortality, as well as comorbidities, associated with the patient's presenting problem(s), the diagnostic procedure(s), and/or the possible management options.

CPT instructs that a physician's MDM must have two of these three elements that meet a certain level (minimal, low, moderate or high) to qualify for the corresponding level of MDM, says Mary I. Falbo, MBA, CPC, president of Millennium Healthcare Consulting Inc. in Lansdale, Pa.

For example: A physician's MDM might include 1) a multiple number of diagnoses or management options and 2) a moderate risk of complications and/or morbidity, translating to a moderate-complexity MDM (which can help justify a level-four E/M service).

Note: See Table 2 on page 7 in the CPT 2004 manual for a full chart of the three MDM criteria and how they determine a level of MDM.
Focus on Level of Risk

The number of possible diagnoses and the amount/complexity of medical records are quantitative criteria you can count, measure and report. Assessing the amount of risk is where coders often stumble because it is much less tangible.

Special help: Many coders are familiar with CMS' Table of Risk, which provides examples of presenting problems, diagnostic procedures, and management options [...]

- Published on 2004-09-23