Medical decision making for E/M services

Along with history and physical examination, the complexity of medical decision making is the third key component for documentation and coding of evaluation and management (E/M) services. Current Procedural Terminology (CPT-4®) identifies four types of complexity in medical decision making: high, moderate, low and straightforward. Each type is defined by meeting or exceeding two of three elements (see Table):

  • number of diagnoses or management options,
  • amount and/or complexity of data to be reviewed and
  • risk of complications, morbidity and/or mortality.

In this month's column, we'll focus on determining the number of diagnoses or management options.

What to document

For each daily encounter, the clinician should document an assessment or clinical impression with a list of diagnoses currently being managed, together with management or evaluation plans.

While a condition may be counted if implied by this documentation, specifically stating the diagnosis or condition is preferred for clinical and audit purposes rather than leaving it open to interpretation by others.

To clarify the severity, each condition ought to be identified as improving, unchanged (stable), or worsening, and details should be given on when each was “resolved.” According to the December 2010 Documentation Guidelines for Evaluation and Management (E/M) Services from the CMS Medical Learning Network (available online) , “For a presenting problem without an established diagnosis, the assessment or clinical impression may be stated in the form of a differential diagnosis as ‘possible,’ ‘probable,’ or ‘rule out’ (R/O) diagnosis.”

There is no official specification of the number of diagnoses or management options that qualifies for the levels of complexity, but generally accepted industry standards do exist.

How to score

The most widely used scoring system was developed in 1995 by the Marshfield Clinic in Marshfield, Wis. The number of problems is multiplied by the number of Marshfield points, and the results are summed to arrive at a total point score, as follows: Self-limited/minor problems (stable, improving or worsening) and established problems (stable, improving) are multiplied by 1; worsening established problems are multiplied by 2; new problems with no additional workup planned are multiplied by 3; and new problems with additional workup planned are multiplied by 4.

The total Marshfield score is then translated into E/M documentation and management points. A score of 1 point is defined as “minimal” complexity, a score of 2 points is defined as “limited” complexity, a score of 3 points is defined as “multiple” complexity, and a score of 4 or more points is defined as “extensive” complexity.

The status of a problem as either new or established is determined by the status of the clinician conducting the visit with the patient. In other words, a problem that has already been established by one physician will be considered new to another physician evaluating the patient for the first time.

Be sure to document every condition currently being managed on the date of service even if the conditions seem interrelated clinically. For example, dehydration causing acute renal failure with hyponatremia may constitute three separate conditions if being individually evaluated or managed via IV normal saline with daily sodium, blood urea nitrogen (BUN) and creatinine levels.