Moving to Medical Decision-Making as the Key Component

by  Erica E. Remer, MD CCDS
May 5th, 2022

Office billing is now based solely on either MDM or total time.

Last week, I declared that it is my opinion that medical decision-making (MDM) should always be one of the components that contributes to selecting (or perhaps, demonstrating) the appropriate level of service (LOS) for the professional fee. In January 2021, MDM became the only component determinant of office or other outpatient evaluation and management (E&M) services. Office billing is now based solely on either MDM or total time. It is rumored that by January 2023, many other E&M services are going to follow suit.

The American Medical Association (AMA) has announced its intent to delete and revise many codes (February 2021: CPT® Editorial Summary of Panel Actions (ama-assn.org), but it is keeping the precise nature of the revisions under wraps. Code sets that will be affected include inpatient and observation care services, consultations (a code set that is not utilized universally), emergency department services, and nursing facility services.

If they are going to MDM-defined LOS, are the guidelines and definitions going to be identical to the office-based ones? I do not know for certain, but the ones they have set out for office E&M services are reasonable and seem generalizable. I don’t think the AMA is likely to redefine the nature of problems; data is data, and the risk of complications and/or morbidity or mortality of patient management is likely to be transferrable. Historically, they try to keep things somewhat standardized, if not identical, across all services.

There is a tool called the Marshfield Audit that has been used for assessing the complexity of MDM, and it is still utilized to judge non-office-based E&M code selection. It is not sanctioned by the Centers for Medicare & Medicaid Services (CMS), but it is used by many auditors to help non-clinician auditors assess the complexity of MDM by clinicians.

AMA has supplied us with a tool to help level-set office-based E&M codes now (https://www.ama-assn.org/system/files/2020-04/e-m-office-visit-changes.pdf), and I predict it will be used more generally after the great E&M revision. Each tool has three factors that are considered when selecting complexity of MDM.

I think comparing and contrasting them will be useful. Let’s start here:

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This article originally published on April 4, 2022 by ICD10monitor.

About Erica E. Remer, MD CCDS

Erica Remer, MD, FACEP, CCDS, has a unique perspective as a practicing emergency physician for 25 years, with extensive coding, CDI, and ICD-10 expertise. As physician advisor for University Hospitals Health System in Cleveland, Ohio for four years, she trained 2,700 providers in ICD-10, closed hundreds of queries, fought numerous DRG clinical determination and medical necessity denials, and educated CDI specialists and healthcare providers with engaging, case-based presentations. She transitioned to independent consulting in July 2016. Dr. Remer is a member of the ICD10monitor editorial board and is the co-host on the popular Talk Ten Tuesdays weekly, live Internet radio broadcasts.