Medical Decision Making in the E & M Visit

Home Provider Part B Publications

The three key components of an Evaluation & Management (E & M) visit are the history, examination, and medical decision making (MDM). This article will focus on the MDM aspect, which is the final component of an E & M visit. By definition, MDM refers to the complexity of establishing a diagnosis and/or selecting a management option. It is the E & M component in which providers assess, advise and assist their patients in managing their health. The end result is an individual plan of care.

MDMs Four Levels
There are four levels (or categories) of E & M medical decision making: straight forward, low complexity, moderate complexity, and high complexity.

Three Elements Within Each Level
There are three elements within each MDM level. Following is a closer look at each individual element.

1.) Number of diagnoses or management options
This element is based on the following:

  • The number and types of problems addressed during the encounter
  • The complexity of establishing a diagnosis
  • The management decisions made by the physician

2.) Amount and/or complexity of data to be reviewed
The amount and/or complexity of data or other information that must be obtained, reviewed and analyzed in order to establish a diagnosis is another indicator of complexity of diagnostic or management problems. Examples of procedures that increase the difficulty of this component include:
  • Obtaining and reviewing old medical records and/or obtaining history from sources other than the patient
  • Seeking advice from others
  • Discussing contradictory or unexpected diagnostic test results with another physician
  • Reviewing the image, tracing, test or specimen ordered to supplement information.

Always remember to document the rationale for ordering diagnostic testing or other ancillary service.

3.) Risk of significant complications, morbidity and/or mortality
The determination of risk is complex and not readily quantifiable. The assessment of risk of the presenting problem(s) is based on the risk related to the disease process anticipated between the present encounter and the next one. The highest level of risk with any one presenting problem(s) (as well as associated comorbidities), diagnostic procedure(s) or management options(s) determines the overall risk.

Documentation Requirements:
Providers can ensure accurate Medicare payments with correct documentation of MDM for E & M services. Either the 1995 or the 1997 E & M Documentation Guidelines may be utilized, but the elements from each set of guidelines may not be mixed. Documentation requirements include:
  • Complete, clear and legible medical records, supporting the medical necessity for the service performed.
  • Two of the three elements must be met or exceeded to qualify for a given type of decision making. If only one component is documented at the highest level the encounter does not qualify for that level.
  • All problems directly addressed in the encounter should be used to determine the level of decision making.
  • For referrals/consults the record should indicate who or where the patient is referred to, the reason for the referral, and who referred them.
  • Documented initiation of, or changes in, treatment.
  • MDM level billed depends on the status of the patient and/or the services performed by the provider.
  • "Rule out" diagnoses should not be counted toward the number of diagnoses managed because it is considered to be part of a new and undiagnosed problem.
  • If predominance of counseling is used to determine the level of an E & M visit, documentation must include the total time of the visit, total time and/or percentage of time spent in counseling, and issues discussed and counseling given.

Time counted toward counseling and total time of visit must be relevant to the issue addressed.

Summary:
Medical decision making is generally easier for an already diagnosed problem than for an undiagnosed one. In addition, problems which are improving or resolving are less complex than those which are worsening or failing to change. Keep in mind that MDM should reflect the nature of the presenting problem. Treatment for a common ailment, such as an ordinary cold, will not usually warrant a comprehensive level exam.

References/Resources:

Beyond the Basics E & M, pp. 5 - 45. March 2005

Evaluation and Management Seminar, WPS Medicare Part B, Medical Review and Provider Outreach and Education Department, August 2006

Medicare Physician Guide: A Resource for Residents, Practicing Physicians, and Other Health Care Professionals at:
http://www.cms.hhs.gov/MLNProducts/downloads/chapter5.pdf adobe portable format document

NCP, PHYS-001, General Coverage for Physicians' Services at: http://www.wpsmedicare.com/policies/wisconsin/index.shtml

On the CMS website http://www.cms.hhs.gov/ link to website outside of wpsmedicare opens a new window

1995 Documentation Guidelines for Evaluation and Management Services at:
http://www.cms.hhs.gov/MLNProducts/Downloads/1995dg.pdf adobe portable format document

1997 Documentation Guidelines for Evaluation and Management Services at:
http://www.cms.hhs.gov/MLNProducts/Downloads/MASTER1.pdf adobe portable format document

Evaluation & Management Services Guide at:
http://www.cms.hhs.gov/MLNProducts/Downloads/eval_mgmt_serv_guide.pdf adobe portable format document

Medicare Benefit Policy Manual (Pub.100-2) at:
http://www.cms.hhs.gov/Manuals/IOM/itemdetail.asp?filterType=none&filterByDID=-99&sortByDID=1&sortOrder=ascending&itemID=CMS012673 link to website outside of wpsmedicare opens a new window

Medicare Claims Processing Manual (Pub. 100-4) at:
http://www.cms.hhs.gov/Manuals/IOM/itemdetail.asp?filterType=none&filterByDID=-99&sortByDID=1&sortOrder=ascending&itemID=CMS018912 link to website outside of wpsmedicare opens a new window