CMS CONSIDERS ELIMINATION OF DG HISTORY AND EXAM REQUIREMENTS WHAT S IT MEAN FOR MDM COMPONENT TWO, AMOUNT AND/OR COMPLEXITY OF DATA TO BE REVIEWED?

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1 THE EDELBERG REPORT CMS CONSIDERS ELIMINATION OF DG HISTORY AND EXAM REQUIREMENTS WHAT S IT MEAN FOR MDM COMPONENT TWO, AMOUNT AND/OR COMPLEXITY OF DATA TO BE REVIEWED? PART THREE IN A FOUR-PART WHITE PAPER SERIES

2 OVERVIEW DECISION MAKING POINT SYSTEM SUMMARY THE EDELBERG REPORT CMS CONSIDERS ELIMINATION OF HISTORY AND EXAM REQUIREMENTS WHAT S IT MEAN FOR MDM COMPONENT TWO, AMOUNT AND/OR COMPLEXITY OF DATA TO BE REVIEWED? This white paper is Part Three of a weekly, four-part, white paper series that is being published by Edelberg and Associates (E+A). Content will focus on Medical Decision Making s (MDM) impact on Evaluation and Management (E/M) code choice. Planned revisions to the CMS Documentation Guidelines (DGs), and their potential mark on the future of emergency medicine reimbursement will also be addressed. Overview The Medicare Physician Fee Schedule proposed rule (Federal Register Volume 82, Number 139, Friday, July 21, 2017) will require significant monitoring and collaboration by all medical specialties before it is finalized. CMS believes that a comprehensive reform of E/M documentation guidelines is necessary as updated guidelines and technological advancements in voice recognition, natural language processing, and user-centered design of EHRs would improve documentation for patient care, and requirements for billing and population health management. We continue to agree with stakeholders that the E/M documentation guidelines should be substantially revised, CMS explains. CMS is currently seeking input from stakeholders regarding guideline modifications that should be implemented in order to reduce the burden associated with the complexity and ambiguity of the current guidelines, and align E/M coding and documentation with the current practice of medicine. CMS is of the opinion that the current focus on history and exam is significantly outdated and burdensome, and that contrasts in MDM are likely the most important factors in distinctions between visit levels. As a result, CMS is considering dramatic changes to the current guidelines in the form of elimination of history and exam documentation requirements. Medical Decision Making and time are the primary focus for guideline revisions, as CMS believes that these are chief factors in distinguishing E/M levels. As time is not a factor in determining emergency medicine E/M levels, MDM would become the key influence provided elimination of history and exam requirements

3 Emergency physicians often order laboratory tests as a component of Medical Decision Making and the emergency department course although the tests referenced in this element are not itemized. Puzzling is the assignment of only one point regardless of how many or how complex the test or tests may be. Decision-Making Point System Review of the official rules for interpreting the key component of Medical Decision Making reveals that the criteria for quantifying physician cognitive labor are quite ambiguous. Realizing that coders and auditors were having a hard time determining the level of Medical Decision-Making, Medicare subsequently developed a more objective Medical Decision-Making Point System. Although not part of the official E/M guidelines, this MDM Point System was distributed to all Medicare carriers to be used on a "voluntary" basis. In point of fact, this is the way CMS grades Medical Decision Making during an audit. This approach uses a matrix of weighted points to answer most of the questions left open by the official E/M guidelines regarding MDM. Instead of subjective words like extensive, the MDM Point System uses a numeric scale to describe the number and nature of the diagnoses being addressed. These issues are quantified using Problem Points. Similarly, the extent of the data reviewed is quantified by using Data Points which reflect the volume and complexity of the information processed by the provider. Risk is determined by referring to the identical Table of Risk used by the official E/M guidelines. Part Three of this four-part white paper series addresses issues inherent in the second component of MDM, Amount and/or Complexity of Data to be Reviewed. The DGs do not assign scores to individual tests or elements, and are not consistent with the Marshfield Clinic scoring system (MCSS) that is used by many payers today. The MCSS is the most objective guideline as it scores the number and types of data managed at the time of the visit, with a higher score assigned to additional resources provided related to data managed. The elements recognized for scoring are demonstrated in the following table: Marshfield Clinic Scoring System Score Review and/or order of clinical laboratory tests (Total of 1 point for all) 1 Review and/or order tests in the radiology section of CPT (Total of 1 point for all) 1 Review and/or order medicine tests (Total of 1 point for all) 1 Discussion of tests results with performing physician (Total of 1 point for all) 1 Decision to obtain old records and/or obtaining history from someone other than patient 1 Review and summarization of old records or obtaining history from someone other than the patient and/or discussion of the case with another health care provider (Total of 2 points for all) 2 Independent visualization of image, tracing or specimen itself (not simply review of the report) (total of 2 points for all)

4 Clinical Laboratory Tests As there is no scoring system referenced in the DGs, one must draw conclusions from the text references. Clinical laboratory tests are referenced as higher complexity when the physician who ordered the test(s) personally reviews the specimen to supplement information from the physician who prepared the test report or interpretation. As we know, clinical laboratory test specimens are not viewed by the emergency physician and values are determined by the lab. Thus, ordering of the tests themselves would not indicate a high level of complexity in the ED. Emergency physicians often order laboratory tests as a component of Medical Decision Making and the emergency department course although the tests referenced in this element are not itemized. Puzzling is the assignment of only one point regardless of how many or how complex the test or tests may be. The need to order and review values of multiple diagnostic laboratory tests are an indication of a higher level of complexity as the physician must review the results and interpret them as part of an overall MDM process. According to the DGs, review of findings must be documented or initialed, and dated by the physician. Radiological Tests (Total of 1 point for all) The DGs reference review of radiological tests in the general context of diagnostic tests which should be documented, signed, and dated. Any discussion of results with the physician who performed or interpreted the study should be documented as well. Direct visualization and independent interpretation of the image previously or subsequently interpreted by another physician should also be documented. In the MCCS, as with clinical laboratory tests, radiological tests are assigned a score of 1 regardless of the number or complexity of tests ordered. In the emergency department, multiple X-Rays, CT scans, and/or MRIs indicate a higher level of complexity, particularly when multiple tests from more than one radiology category are required. Unfortunately, this is not addressed in either the DGs or the MCSS. Medicine Tests (Total of 1 point for all) There is no specific reference in the DGs to tests in the Medicine section of CPT. The MCSS distinguished these tests from those referenced in the Laboratory and Radiology Tests section of the DGs. The Medicine section tests utilized are dependent on the specialty. For example, EKG and Rhythm Strips - located in the Medicine section - are both billable at the discretion of the physician when documented appropriately. Although not itemized, medicine tests encompass all diagnostic studies listed in the Medicine section of the CPT manual. For emergency medicine, this would include ordering of common tests such as EKGs and Rhythm Strips. Discussion of any Tests Results with Performing Physician (Total of 1 point for all) When a physician feels the need to discuss study results with the physician who performed or interpreted the study, the DGs consider it an indication of the complexity of data being reviewed, but no score is assigned. Conversely, the MCSS assigns 1 point to the process, but defines this element as discussion of test results with the performing, not the interpreting, physician

5 A scoring system that recognizes the additional value of multiple diagnostic tests required by patient acuity is essential. For instance, should not MDM be higher if a physician orders more than one lab test during the visit? Decision to Obtain Old Records and/or Obtaining History from Someone Other than Patient The DGs address the importance of documenting any decision to obtain old record or additional history from family, caretaker, or other source to supplement what is obtained from the patient, but do not assign any value to this resource. This is commonly documented as Old record requested in ED charts when the physician requests patient records from earlier dates of service. When family is involved in the ED visit and provides additional information, this element would apply as long as the discussion and source of information (e.g., son, daughter, etc.) is documented in the medical record. The MCSS assigns a score of 1 to this element. Review and Summarization of Old Records or Obtaining History from Someone Other than the Patient and/or Discussion of the Case with Another Health Care Provider (Total of 2 points for all) The DGs reference relevant finding from the review of old records, and/or the receipt of additional history from the family, caretaker, or other source should be documented. If there is no relevant information beyond that already obtained, it should be documented. Notations of Old records reviewed or additional history obtained from family would not be sufficient. Thus, this element is differentiated from the request for records by the requirement for documenting the discussion, prior entries, and/or date and signature of the physician. In the MCSS, this element is defined as Review and summarization of old records and/or obtaining history from someone other than the patient and/or discussion of case with another health care provider. Requesting a consult in the ED and discussing the findings (discussion of case with another health care provider) would also qualify. This element is assigned an additional score of 2 points from the request for the record or additional history which is assigned a score of 1. Thus, ordering/requesting additional history, and documenting the information obtained would provide a total score of 3. This is not clarified in either the DGs or the MCSS. That said, it is a generally accepted method for scoring both request and review of old records or additional information. Independent Visualization of Image, Tracing, or Specimen Itself (not simply review of the report) (Total of 2 points for all) The DGs reference this element as documentation of the direct visualization and independent interpretation of an image, tracing or specimen previously or subsequently interpreted by another physician. For diagnostic studies interpreted in the ED or other areas of the hospital, a documented interpretation would qualify. The MCSS assigns 2 points to this element and defines it as independent visualization of image, tracing or specimen itself (not simply review of report.) Summary Although the Amount and/or Complexity of Data to be Reviewed element of MDM is the most objective, there are still numerous areas that will need to be refined and/or defined to make this element quantifiable for objective coding. A scoring system that recognizes the additional value of multiple diagnostic tests required by patient acuity is essential. For instance, should not MDM be higher if a physician orders more than one lab test during the visit? And don t some lab tests or types of x-rays indicate a higher risk than others? Do multiple or certain tests act as a proxy for higher acuity?

6 Some payers state that the value of ordering a test is included in the interpretation or visualization of that test. It is our belief that the decision to order one test or multiple tests adds to the complexity of decision making as does the act of interpreting or visualizing a test when determining the course of patient treatment. Under the existing MCSS, one point would be assigned under medicine section tests and two points would be assigned under independent visualization. It is reasonable to count the ordering of tests separately from the interpretation or visualization of the services. In addition, multiple labs, x-rays, or tests under the medicine section of CPT should be factored into the Amount and/or Complexity of Data to be Reviewed. Issues inherent in the Table of Risk will be addressed in Part Four of this four-part white paper series. Comments and/or questions should be addressed to Caral@Edelberg.com Subject Line: Edelberg on Coding. Caral Edelberg, CPC, CPMA, CAC, CCS-P, CHC Founder and Chairman Michael Sparks President