The Devil is in the Data Details

by  J. Paul Spencer, CPC, COC
May 4th, 2018

As an auditor who has reviewed thousands and thousands of encounter documents for level of service, a predictable pattern has merged when it comes to the Medical Decision Making (MDM) component that has attracted my attention.

Let's delve into the formula for a moment. There are four levels of complexity under MDM: Straightforward, Low, Moderate and High. The level of complexity is defined by determining the level of elements of MDM: the number of diagnoses or management options, the level of risk and the amount and complexity of data. Selecting the level of complexity is based on the highest two of three levels as defined by the elements documented.

When auditing E/M services, I find that providers do a fairly good job of identifying the number of diagnoses, and the level of risk, even in the sometimes over-regimented world of the electronic medical record, can be easily discerned from documentation.

This brings us to the amount and complexity of data, our topic of discussion for purposes of this article. Determining the complexity of data occurs on the following point system:

• Review and/or order of labs - 1 point
• Review and/or order of radiological imaging - 1 point
• Review and/or order of medical tests (90000 series of CPT) - 1 point
• Discussion of test results with performing physician - 1 point
• Decision to obtain old records/decision to obtain history from someone other than the patient - 1 point
• Review & summarization of old records/obtaining history from someone other than the patient/discussion of case with another health care provider - 2 points
• Independent visualization of image, tracing or specimen - 2 points When considering data, providers tend to either misinterpret or neglect the last two items on this list.

A "review and summarization of old records" means reviewing records that the current provider of service has not previously had at his / her disposal. Credit is not given for a review and summarization of the provider's own records relating to the patient.

"Obtaining history from someone other than the patient" refers to anyone other than the patient that provides relevant history for the patient at the time of service. This differs from a decision to obtain history from someone other than the patient, which refers to obtaining history from another source at the conclusion of the encounter.

In the case of a "discussion of case with another healthcare provider", there should be detailed documentation of what was discussed with the other provider within the body of the note for the encounter.

The independent visualization of an image, tracing or specimen is more than simply a review of an existing report. "Independent visualization" is the viewing of an x-ray or other test, with the provider's own interpretation of what he or she is seeing. Providers often miss this data point, and instead credit themselves erroneously with one point for the review of the test. It is important that these impressions from the independent visualization be documented fully in order to gets the full two points of credit under data.

Of course, crediting these data points will depend largely on the provider capturing these items, but if a provider is in the habit of performing these tasks without accompanying details, the opportunity is there to better define a higher level of complexity of patient encounter.

This Week's Audit Tip Written By:

J. Paul Spencer, CPC, COC

Paul is a Senior Compliance Consultant for our parent organization, DoctorsManagement.

References:

• BC Advantage Article