UASI is on the front lines actively working with our clients to help them comply with the biggest change in evaluation and management (E/M) coding since 1997. The new office visit E/M code levels are assigned based on either medical decision making (MDM) or total time. The complex MDM rules make it really easy to under report office visit services. To accurately capture these services, you need to completely change how you document and count MDM.
For example, documenting the number and complexity of problems addressed at the encounter (one of the three elements that determines the MDM level) presents some unique challenges. It is important to differentiate between an acute uncomplicated illness (low complexity) and an acute illness with systemic symptoms (moderate complexity). The concept of “problems addressed” is also confusing. These terms are defined in the new guidelines, but providers and coders are struggling to translate that to visit note documentation. UASI has tools to help with that. The table below is an example of documentation tips we are gathering to help providers and coders adjust to the new rules.
Documentation of the Number and Complexity of Problems Addressed at the Encounter
|DOCUMENTATION REQUIRED||DOCUMENTATION TIP EXAMPLE|
|Include all acute and chronic diagnoses/problems evaluated/ treated/addressed during the encounter||Type II DM with bilateral heel ulcers|
|Provide specificity for each diagnosis or problem||Acute recurrent sinusitis of maxillary and frontal sinuses|
|Link underlying conditions and the manifestation(s)||Pulmonary fibrosis due to radiation|
|Specify if chronic conditions are stable vs. decompensating, exacerbated, or progressing||Decompensated systolic heart failure; worsening anemia due to GI blood loss|
|Identify any side effects from treatment||COPD with steroid induced diabetes|
|Specify any systemic or complications of an acute illness||Strep throat with fever and rash|
|Specify if injuries are simple or complicated||Complicated high ankle sprain|
|Provide potential differential diagnoses for undiagnosed problems||RUQ breast mass fibroadenoma vs. carcinoma|
|Specify when condition is a potential threat to life or bodily function||COPD exacerbation with impending respiratory failure|
Contact UASI today with questions or to set up an exploratory call with our E/M experts at firstname.lastname@example.org. Let’s make sure you’re on the right track!