Document Medical Decision Making (MDM) with Ease

How to Document Medical Decision Making

Now that we’ve had a month to settle into the new Evaluation and Management (E/M) coding rules that went into effect at the beginning of the year, the questions are getting more specific and refined. We are delighted when we receive thought-provoking questions at our HelpDesk that reveal doctors’ critical thinking as they begin to use this new coding process. It allows us to clarify what documentation should look like as the coding takes place.

As our members began to grapple with this new procedure, the myriad of questions that we got revolved around exactly how to document the information to justify the code. When using time to select the proper code, it’s very straightforward. However, doctors are struggling with how to document medical decision making (MDM) to “show their work” and how they arrived at the proper code.

Document for Medical Necessity

Remember, in this new coding convention, all the individual elements of history and examination that we used to document for coding’s sake may no longer be necessary. The new rules require a “medically appropriate” history and examination. These must also document the medical necessity for care as it always did. Likewise, your documentation must show that you followed the standard of care. However, none of this weighs into the final selection of the code in the way that it used to.

One of the main reasons for the change to this new coding convention was the Patients over Paperwork initiative from the Department of Health and Human Services. The goal was to eliminate “note bloat” where providers felt they had to overflow the documentation with what seemed to be extraneous information to qualify for a certain code. Doctors need to avoid this same practice as they look for ways to properly document their decision-making process when coding using medical decision making.

Medical Decision Making: What Not to Do

One of our members recently forwarded documentation of a new patient’s E/M visit and asked our opinion on whether the documentation warranted the 99204 that she thought it did. The patient was in a severe car accident and had a brief loss of consciousness. The patient went to the hospital and was admitted for overnight observation based on other comorbidities suffered. When the patient made a chiropractic appointment, this doctor reached out to the hospital and received the hospital records and the MRI results. On the date of the patient’s initial visit, before seeing the patient, the doctor reviewed the records and the MRI. As a result of the findings of the visit, the doctor ordered a cervical Davis series of X Rays. Along with this, the provider documented the history, examination, assessment, diagnosis, and treatment plan.

When reviewing the documentation, it was clear this doctor was trying to list every element of responsibility to meet the 99204 definition but didn’t use clinical language. Instead, she was trying to document the terms of the coding process which wasn’t appropriate. For example, she used language like:

As we explained, this is really the coder’s job and not appropriate in the actual health record. We showed her a better way.

Use the Initial Assessment as Intended

Remember, the purpose of the initial assessment is to outline everything learned in the history and examination, to restate clinical opinions about the patient, his/her comorbidities, and any complicating factors, and to outline the prognosis. This is the perfect place to summarize the elements of the critical thinking process you used to arrive at your proper code. Consider how this differs from the earlier example:

In this assessment, we’ve outlined all the required elements that allow for coding to a 99204 level of service. We’ve done so as part of the documentation to make it easy for a coder or auditor to see the doctor’s clinical thinking and rationale.

As we continue to evolve through the coding changes for 2021, we invite you to consider a chart review or to schedule a brief consultation to review a single E/M service. The eyes of an expert can make all the difference in your peace of mind and your bottom line.