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FY21 E/M Office Visit MDM Part 2: Amount/Complexity of Data Reviewed

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 amount and/or complexity of data reviewed or analyzed at the encounter (one of the three elements that determines the MDM level) presents some unique challenges. When a provider orders a test, the review of that test is included and should only be counted once. This means providers need to indicate whether a test s/he reviewed is one that s/he ordered on a previous encounter. Current documentation practices do not provide this level of detail. 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 Amount and/or complexity of Data to be Reviewed and Analyzed

Identify each individual source of external documentationDocument each unique source, the type of report and summarize pertinent findings
Unique lab test reviewed and summarize pertinent and clinically relevant findings for each testDocument the clinically relevant abnormal values or normal results for each test. Example: CBC reviewed and revealed Hct down from 34.5% to 33.2%
Identify each unique radiology or diagnostic exam reviewed and summarize pertinent and clinically relevant findings for eachMRI brain showed no signs of aneurysm or bleeding
Identify any individual (parent, guardian, surrogate, spouse, witness) who provides a complete or partial historyPatient’s history was provided by the patient’s spouse due to patient’s cognitive impairment
Independent interpretation of test performed by another MD/QHPReviewed chest films from ER visit to check for any acute changes in addition to his chronic COPD
Identify any physician or QHP and summarize discussion regarding test interpretation, patient management and/or treatment options that are not separately being reportedDiscussed recent cath results and underlying co-morbid conditions with cardiologist to determine if CABGs or PTCA was recommended

Contact UASI today with questions or to set up an exploratory call with our E/M experts at UASI has specialty-specific documentation tips to help all your providers.