MCCG 240 Week 5 Portfolio Project - Level of EM Service - Medical Decision Making and Time

Ciara Santos 11/26/2023 MCCG240 Week 5: Portfolio Project - Level of E/M Service – Medical Decision Making and Time Levels of E/M Services Within each category or subcategory of E/M service based on MDM or time, there are three to five levels of E/M services available for reporting purposes. The levels of E/M services are not interchangeable among the different categories or subcategories of service. For example, the first level of E/M services in the subcategory of office visit, new patient, does not have the same definition as the first level of E/M services in the subcategory of office visit, established patient. Each level of E/M services may be used by all physicians or other qualified health care professionals. Guidelines for Selecting Level of Service Based on Medical Decision Making Four types of MDM are recognized: straightforward, low, moderate, and high. The concept of the level of MDM does not apply to 99211, 99281. MDM includes establishing diagnoses, assessing the status of a condition, and/or selecting a management option. MDM is defined by three elements. The elements are: ■ The number and complexity of problem(s) that are addressed during the encounter. ■ The amount and/or complexity of data to be reviewed and analyzed. These data include medical records, tests, and/or other information that must be obtained, ordered, reviewed, and analyzed for the encounter. This includes information obtained from multiple sources or interprofessional communications that are not reported separately and interpretation of tests that are not reported separately. Ordering a test is included in the category of test result(s) and the

review of the test result is part of the encounter and not a subsequent encounter. Ordering a test may include those considered but not selected after shared decision making. For example, a patient may request diagnostic imaging that is not necessary for their condition and discussion of the lack of benefit may be required. Alternatively, a test may normally be performed, but due to the risk for a specific patient it is not ordered. These considerations must be documented. Data are divided into three categories: ● Tests, documents, orders, or independent historian(s). (Each unique test, order, or document is counted to meet a threshold number.) ● Independent interpretation of tests (not separately reported). ● Discussion of management or test interpretation with external physician or other qualified health care professional or appropriate source (not separately reported). ■ The risk of complications and/or morbidity or mortality of patient management. This includes decisions made at the encounter associated with diagnostic procedure(s) and treatment(s). This includes the possible management options selected and those considered but not selected after shared decision making with the patient and/or family. For example, a decision about hospitalization includes consideration of alternative levels of care. Examples may include a psychiatric patient with a sufficient degree of support in the outpatient setting or the decision to not hospitalize a patient with advanced dementia with an acute condition that would generally warrant inpatient care, but for whom the goal is palliative treatment. Shared decision making involves eliciting patient and/or family preferences, patient and/or family education, and explaining risks and benefits of management options. MDM may be impacted by role and management responsibility. When the physician or other qualified health care professional is reporting a separate CPT code that includes interpretation and/or report, the interpretation and/or report is not counted toward the MDM when selecting a level of E/M services. When the physician or other qualified health care professional is reporting a separate service for discussion of management with a physician or another qualified health care professional, the discussion is not counted toward the MDM when selecting a level of E/M services. The Levels of Medical Decision Making (MDM) table (Table 1) is a guide to assist in selecting the level of MDM for reporting an E/M services code. The table includes the four levels of MDM (ie, straightforward, low, moderate, high) and the three elements of MDM (ie, number and complexity of problems addressed at the encounter, amount and/or complexity of data reviewed and analyzed, and risk of complications and/or morbidity or mortality of patient management). To qualify for a particular level of MDM, two of the three elements for that level of MDM must be met or exceeded.

requiring hospital inpatient or observation level of care requiring an independent historian(s) (For the categories of independent interpretation of tests and discussion of management or test interpretation, see moderate or high) Moderate Moderate  1 or more chronic illnesses with exacerbation, progression, or side effects of treatment  2 or more stable, chronic illnesses  1 undiagnosed new problem with uncertain prognosis  1 acute illness with systemic symptoms  1 acute, complicated injury Moderate (Must meet the requirements of at least 1 out of 3 categories) Category 1: Tests, documents, or independent historian(s)  Any combination of 3 from the following: -Review of prior external note(s) from each unique soure; -Review of the result(s) of each unique test -Ordering of each unique test; -Assessment requiring an independent historian(s) Category 2: Independent interpretation of tests  Independent interpretation of a test performed by another physician/other qualified health care professional (not separately reported) Category 3: Discussion of management or test interpretation  Discussion of management or test interpretation with external physician/other Moderate risk of morbidity from additional diagnosis testing or treatment Examples only:  Prescription drug Management  Decision regarding minor surgery with identified patient or procedure risk factors  Decision regarding elective major surgery without identified patient or procedure risk factors  Diagnosis or treatment significantly limited by social determinants of health

qualified health care professional /appropriate source (not separately reported) High High  1 or more chronic illnesses with severe exacerbation, progression, or side effects or treatment Extensive (Must meet the requirements of at least 2 out of 3 categories) Category 1: Tests, documents, or independent historian(s) Any combination of 3 from the following:  Review or prior external note(s) from each unique source  Review of the result(s) of each unique test  Ordering of each unique test  Assessment requiring an independent historian(s) Category 2: Independent interpretation of tests  Independent interpretation of a test performed be another physician/other qualified health care professional (not separately reported) Category 3: Discussion of management or test interpretation  Discussion of management or test interpretation with High risk of morbidity from additional diagnostic testing or treatment Examples only:  Drug therapy requiring intensive monitoring for toxicity  Decision regarding elective major surgery with identified patient or procedure risk factors  Decision regarding emergency major surgery  Decision regarding hospitalizatio n or escalation of hospital-level care  Decision not to resuscitate or to de- escalate care because of poor prognosis.  Parental