Decision-Making Point System

A casual review of the official rules for interpreting the key component of Medical Decision-Making shows that the criteria for quantifying physician cognitive labor are quite ambiguous.   Medicare discovered that auditors were having a hard time nailing down the level of Medical Decision-Making during the medical review process.  In response to this problem, a more objective Medical Decision-Making Point System was developed by CMS. 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 your Medical Decision-Making will be graded in the event of 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 the MDM .  Instead of vague 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 physician.  Risk is determined by referring to the identical table of risk used by the official E/M guidelines. 

Problem Points

The “nature and number of clinical problems” are quantified into Problem Points by referring to the following table:

The above table is fairly self explanatory.  An example of a “self-limited or minor” problem may be a common cold or an insect bite.  An “established problem” refers to a diagnosis which is already known to the examiner, such as hypertension, osteoarthritis or diabetes.  An example of a “new problem with no additional work-up planned” may be a new diagnosis of essential hypertension.  Examples of “new problem, with additional work-up planned” may include any new clinical issue which requires further investigation such as chest pain, proteinuria, anemia, shortness of breath, etc

Coding Tip: Problems which are not being addressed specifically by the physician during the encounter may still be counted if they significantly increase the complexity of the cognitive labor required.  For example, consider a patient with diabetes who is being evaluated by a vascular surgeon for a lower extremity revascularization procedure.  It would be appropriate for the surgeon to include diabetes as an “established problem, stable” when calculating the problem points.  This is because the comorbidity of diabetes does significantly influence the risk of the procedure and the complexity of the post operative management.

Coding Tip: Problems are defined relative to the examiner, not the patient.  Even if the problem was previously known to other physicians or to the patient, it is still considered new to you if you are seeing the patient for the first time. This situation arises often in the case on consultations.

Data Points

The “amount and complexity of the data reviewed” are quantified by referring to the following table:  

 The physician should be aware that no “double dipping” is allowed.  For example, if you review lab results and order labs during the same visit, you only get one point (not one point for ordering and one point for reviewing).  This same rules applies to imaging  studies or other medicine tests such as EKGs or PFTs.  Commonly overlooked points are those garnered for obtaining or reviewing old records.  If you do review old records, you must summarize your findings in the chart.  It is not acceptable to just say, “Old records were reviewed.” 

You only get ONE point for reviewing OR ordering lab tests (NOT one point for ordering AND one point for reviewing).

Lab tests refer to CPT codes 80002 - 89399 which include results of analysis of any specimen such as blood, urine, CSF, feces, synovial fluid, semen, etc.  These may include routine chemistry tests, CBC, hormonal assays, microbiologic cultures, cytogenetic studies, gross or microscopic pathology results, or evocative testing such as a cosyntropic stimulation test.

Remember, you only get ONE point for ordering OR reviewing results of X-rays (NOT one point for ordering AND one point for reviewing results).

X-rays refer to CPT codes 70010 - 79999 which include imaging studies such as plain X-rays, myelography, CT scans, MRIs, urography, angiography, venography, DEXA scans, diagnostic ultrasounds, nuclear medicine studies and PET scans.

Remember, you only get ONE point for reviewing OR ordering these tests (NOT one point for ordering AND one point for reviewing results).

Medicine tests refer to CPT codes 90700 - 99199 which include EKGs, EEGs, PFTs, echocardiograms, cardiac catheterizations, cardiac stress tests, audiometry, speech or swallow studies, pacemaker interrogations, arterial or venous doppler studies, plethysmography, non-invasive arterial studies (such as ABIs), transcranial doppler studies, allergy testing, sleep studies, EMGs, evoked potentials, tensilon testing and nutritional assessments

You can get one data point for discussing a test with the performing physician.  For example, if you speak with the cardiologist who interpreted an echo cardiogram, or if you discuss the results of an endoscopy with the performing gastroenterologist you get one point.

It is important to remember that you must document that the discussion occurred and summarize the findings in the chart in order to take credit for this type of cognitive labor.

You can get two data points if you personally review an image, tracing or specimen.  It does not matter if there is an official report already in the record (for example an official interpretation from a radiologist for a chest X-ray).  All that is required is that you personally eye-ball the image, tracing or specimen AND record YOUR findings in the chart.

It is not known (and in fact be unknowable) whether or not there is a limit on the amount of points you can accumulate for personally reviewing an image, tracing or specimen.  For example, if you are admitting a patient with chest pain it would not be unusual for you to look at a chest X-ray and an EKG.  As long as you record your findings in the chart, it seems reasonable that you would be able to claim four data points for this cognitive labor. To be on the safe side, however, we recommend that you pose this specific question to your Medicare carrier.

You get one data point for "deciding" to obtain old records.  In order to claim this point you must document your specific intentions in the chart.  Many physicians routinely decide to get old records, but forget to mention it in the note.  This is a fairly easy data point to pick up.

This is probably the most often overlooked source of data points for most physicians.  Whenever we see a patient for the first time (in the hospital or in the office), we almost ALWAYS have some old records to review.  This could take the form of some office notes sent over from the referring physician or a review of the old chart when you see a patient in the hospital. 

In order to claim these two data points, you MUST record your findings in the chart after you review the records.  You cannot simply say, "old records reviewed."

In my practice, when I get a renal consult or do an admission, I make a point of dictating a special section in my note, which I call "Review and Summation of Old Records." 

For example :

Review and Summation of Old Records

" I reviewed the patient's chart dating back for the past five years.  He was most recently admitted for a CHF exacerbation about six months ago.  At that time his creatinine was 1.8.  Looking back over previous admissions, his creatinine has been running in the 1.5 to 1.8 range.  There have been no episodes of ARF in the past."

Coding Tip: Notice that points can accumulate quickly if you personally review an image, tracing or specimen.  You can still claim these points, even if the image, tracing or specimen has been reviewed by another physician (as when a radiologist provides an official interpretation for an X-ray).  However, you must include your own interpretation in the chart in order to claim these points. 

Adding it All Up: How to Calculate Your Cognitive Labor

After calculating the Problem Points and the Data Points and stratifying the level of risk, the overall complexity of MDM is determined by referring to the yet another table:

MDM Points Table
(Two out of three must be present to qualify for a given level of MDM)

Example:
Suppose you see a patient in the office with stable diabetes and sub-optimally controlled hypertension.  After checking routine labs, you decide to increase the patient’s lisinopril from 10 to 20 mg po qd.  If you calculate the individual points and assign a level of risk, the MDM table for this encounter would look like this:

Since it only takes two out of three elements to qualify for any level of MDM , it is clear that this encounter qualifies for “Moderate Complexity” medical decision-making because of:

·        Three Problem Points  (one point for diabetes-- established problem, two points for hypertension—established problem, worsening)
·        One  Data Point for reviewing labs
·        Moderate Risk due to the management option selected of “prescription drug management”
       
Coding Tip: The MDM point system provides a repeatable and objective way for the physician to measure the cognitive labor required to address the clinical issues of any encounter.  Many physicians systematically underestimate the value of their medical decision-making.  This occurs because there is a tendency to equate “routine” thought processes with “straightforward” medical decision-making which is simply not true.  Utilizing the objective MDM point system can help you avoid this self-deprecating pattern of behavior.