Where and How MDM is Indicated and What OP Can and Cannot Do

Version 20.13
  Take me to all 2021 Office Visit E/M Coding Resources!

Important Note about the Development of these Features

It is important to note that the details of what “should” and “should not” count are evolving and the developments in OP can only align with what we know to be true at the time of development. We expect that there will be modifications to the enhancements as more is learned from both the industry and our practices. All coding recommendations are suggested based on information that can be tracked in OP.

There are 3 elements of Medical Decision Making: Problems Addressed, Data Reviewed, and Risk of Complications. There are 4 levels of Medical Decision Making: Straightforward, Low, Moderate, and High. In order to qualify for a particular level of MDM, two of the three elements for that level of MDM must be met or exceeded. After reviewing where and how each element is indicated in OP, review the definitions and some examples for each element.

Problems Addressed: Number and complexity of problems addressed

  OP Can:

• Count the number of problems/diagnoses in the Assessment

• Count if they are one of the following 8 categories if the user specified at the template or Assessment level:

-Acute-minor, Acute-uncomplicated, Acute-complicated, Acute-severe, Chronic-stable, Chronic-unstable/increased, Chronic-recurring, Chronic-severe

• Default the MDM element level in Coding section of note to Minimal

  OP Cannot:

• Determine if the acute problem is self-limited or minor vs Acute- uncomplicated

• Determine if an acute injury is "complicated"

• Determine if an acute new problem has an "uncertain prognosis"

Where and How Problems Addressed are Indicated in OP (Click thumbnail to enlarge image)

Problem Status in Encounter Templates
Clinical tab > Encounter Templates
Problem Status in Assessment Section of Note
Encounter Note > Assess/Plan
Use the Problem Status drop-down located in the Diagnosis section of the Encounter Note tab in the Encounter Template Editor to set the default Problem Status for the diagnosis. This can be changed in the Encounter, if appropriate.

Tip: Setting the Problem Status at the template level should be done at the provider's discretion. It may not be appropriate to assign a default Problem Status to all Encounter templates. Depending on the nature of the diagnosis, it may be best to determine Problem Status during the individual Encounter. When Problem Status is added to templates, the provider should verify it is appropriate when applied to an individual patient note and adjust if necessary.

Use the Problem Status drop-down located in the Diagnosis section of the Assessment section of the Encounter Note to select the Problem Status for each diagnosis. If the Problem Status is already populated because it was set at the template level, the provider should verify it is appropriate to the Encounter and adjust if necessary.

Data Reviewed/Analyzed: Amount and/or complexity of data reviewed and analyzed

OP Can:

•Disregard the selection of "Self" for Independent Historian from the data review count.

• Count direct lab interface (DTI) orders and in-house labs by counting each unique lab in a requisition separated by a semi-colon.

• Count surveys reviewed on the date of visit that do not carry their own CPT charge.

• Count each lab marked reviewed today on the date of visit that was not counted as an ordered lab for the visit.

• Count each unique test ordered. Each order counts as a valid action. For example, if a provider orders 3 labs, then the provider has performed 3 actions.


Tip: There must be an order in the Diagnostic Tests tab with at least a status of Pending. This can happen directly if the provider orders tests from the Diagnostic Tests tab. Or, if providers create a task for the order, the task must have a status of Completed, and the order itself must be in at least a Pending status.


Note: You cannot double-dip and count a test that you ordered when that test is being separately reported and the work of interpretation and report is under that code descriptor. Examples: Developmental testing (96112-96113), Spirometry (94010, 94060), and EKG (93000 or 93010).


Some codes that do not include the terminology “interpretation and report” in the code descriptor: 84181, 84182, 85390, 86152, 86153, 88173, 88791, 88312, 88371, 88375, 89049.

OP Cannot:

• Count paper copies of reports initialed.

• Know which kind of scanned report someone is reviewing because users can label things any way they want. Providers are held accountable for their decision to label documents appropriately.

Valid Document Types

:Chart

:Chart-Med Hx

:Diagnostic Test

:Referral Letter

Miscellaneous

Invalid Document Types

Disclosure*

Photo ID

:Insurance

:Patient Consent

:CHADIS, :Questionnaire**

:CDA***

:Forms

* By definition, these are created by the practice
** This would double-count what you already have in Surveys
*** These are always outgoing

Where and How Data Reviewed/Analyzed is Indicated in OP (Click thumbnail to enlarge image)

 Document Management Visit Info section of Note Couns/CoC section of Note Diagnostic Tests

Use the Mark Reviewed button. This now counts a re-review of the document if the date = today.

 Use the Independent Historian drop-down list of patient's Family Contacts or the free-text field to document who is providing information to the provider.

Assisted by translator * checkbox to indicate a translator assisted the provider. 


* Feature Development Note:

- As of 11/24, this is under consideration by AMA as a valid MDM action and therefore will not be counted by OP at this time.

• Use the Discussed with field to select a name from Address Book or the patient's Clinical Contacts. Documentation of the discussion must also be entered into the Coordination of Care field.
• Use the Independent Interpretation of Tests checkbox to indicate such interpretation. Documentation of the interpretation must also be entered into the Coordination of Care field.
Use the Reviewed Today * button to indicate that a historical result was reviewed on the date of the Encounter, given it is relevant to the patient's current visit/reason for seeking care.

* Feature Development Notes:
- As of 11/30, the decision to exclude labs previously reviewed by you or another provider in the practice was made by the AMA, and OP plans to deliver the ability to filter these out in a future release.

Risk of Complications and/or Morbidity or Mortality of Patient Management

OP Can:

• Count Risk Assessment items eligible to be counted as a Social Determinants of Health (SDOH) that are marked pertinent for today's visit.

• Count when a provider issues a prescription with a linked NDC. The prescription needs to have one of the following status to be counted toward MDM:

- SENT

- PRINTED

- FAXED

- PICKED UP

- CALLED

- DELIVERED

- MAILED

- PENDING

OP Cannot:

Filter out ineligible OTC medications. The provider must decide whether or not to include an OTC medication when coding the Encounter.

• Default to an element level of Risk. The user must select or perform requirements for Moderate Risk calculation.

• Determine the complications of morbidity/mortality of patient management. For example, the decision to perform minor surgery and/or prescription management of chronic conditions. The provider must decide whether or not to adjust the Risk Level when coding the Encounter.

• Support calculating Minimal, Low, and/or High Risk levels

Where and How Risk of Complication is Indicated in OP (Click thumbnails to enlarge images)

Risk Assessment Editor
Risk Assessment in an Encounter
Assess/Plan
Use the SDOH checkbox to mark Risk questions as eligible for SDoH. By default, Food Insecurity, Health Literacy, and Housing Insecurity are selected.
Use the Pert (pertinent) checkbox to indicate which Risk Factors are pertinent to the visit.
Use the Managing patient's medication checkbox located in the Plan section of the Encounter to document that prescriptions were created or managed on the date of the visit.
Version 20.12
  Take me to all 2021 Office Visit E/M Coding Resources!

Important Note about the Development of these Features

It is important to note that the details of what “should” and “should not” count are evolving and the developments in OP can only align with what we know to be true at the time of development. We expect that there will be modifications to the enhancements as more is learned from both the industry and our practices. All coding recommendations are suggested based on information that can be tracked in OP.

There are 3 elements of Medical Decision Making: Problems Addressed, Data Reviewed, and Risk of Complications. There are 4 levels of Medical Decision Making: Straightforward, Low, Moderate, and High. In order to qualify for a particular level of MDM, two of the three elements for that level of MDM must be met or exceeded. After reviewing where and how each element is indicated in OP, review the definitions and some examples for each element.

Problems Addressed: Number and complexity of problems addressed

  OP Can:

• Count the number of problems/diagnoses in the Assessment

• Count if they are one of the following 8 categories if the user specified at the template or Assessment level:

-Acute-minor, Acute-uncomplicated, Acute-complicated, Acute-severe, Chronic-stable, Chronic-unstable/increased, Chronic-recurring, Chronic-severe

• Default the MDM element level in Coding section of note to Minimal

  OP Cannot:

• Determine if the acute problem is self-limited or minor vs Acute- uncomplicated

• Determine if an acute injury is "complicated"

• Determine if an acute new problem has an "uncertain prognosis"

Where and How Problems Addressed are Indicated in OP (Click thumbnail to enlarge image)

Problem Status in Encounter Templates
Clinical tab > Encounter Templates
Problem Status in Assessment Section of Note
Encounter Note > Assess/Plan
Use the Problem Status drop-down located in the Diagnosis section of the Encounter Note tab in the Encounter Template Editor to set the default Problem Status for the diagnosis. This can be changed in the Encounter, if appropriate.

Tip: Setting the Problem Status at the template level should be done at the provider's discretion. It may not be appropriate to assign a default Problem Status to all Encounter templates. Depending on the nature of the diagnosis, it may be best to determine Problem Status during the individual Encounter. When Problem Status is added to templates, the provider should verify it is appropriate when applied to an individual patient note and adjust if necessary.

Use the Problem Status drop-down located in the Diagnosis section of the Assessment section of the Encounter Note to select the Problem Status for each diagnosis. If the Problem Status is already populated because it was set at the template level, the provider should verify it is appropriate to the Encounter and adjust if necessary.

Data Reviewed/Analyzed: Amount and/or complexity of data reviewed and analyzed

OP Can:

• Count surveys reviewed on the date of visit that do not carry their own CPT charge.

• Count each lab marked reviewed today on the date of visit that was not counted as an ordered lab for the visit.

• Count each unique test ordered. Each order counts as a valid action. For example, if a provider orders 3 labs, then the provider has performed 3 actions.


Tip: There must be an order in the Diagnostic Tests tab with at least a status of Pending. This can happen directly if the provider orders tests from the Diagnostic Tests tab. Or, if providers create a task for the order, the task must have a status of Completed, and the order itself must be in at least a Pending status.


Note: You cannot double-dip and count a test that you ordered when that test is being separately reported and the work of interpretation and report is under that code descriptor. Examples: Developmental testing (96112-96113), Spirometry (94010, 94060), and EKG (93000 or 93010).


Some codes that do not include the terminology “interpretation and report” in the code descriptor: 84181, 84182, 85390, 86152, 86153, 88173, 88791, 88312, 88371, 88375, 89049.

OP Cannot:

• Discount in-house labs from the total labs ordered count 

  Feature Development Note: As of 11/24, this decision was made by AMA, and OP plans to deliver the ability to filter these out in a future release.

• Count lab orders using direct lab interface (DTI) due to orders not being generated from the requisition until results are received from the lab.

- The ability to accommodate this workflow will be addressed in a future release of OP.

• Count paper copies of reports initialed.

• Know which kind of scanned report someone is reviewing because users can label things any way they want. Providers are held accountable for their decision to label documents appropriately.

Valid Count Categories

:Chart-Med Hx

:Diagnostic Test

:Referral Letter

Miscellaneous

Invalid Count Categories

Disclosure*

Photo ID

:Insurance

:Patient Consent

:CHADIS, :Questionnaire**

:CDA***

:Forms

* By definition, these are created by the practice
** This would double-count what you already have in Surveys
*** These are always outgoing

Where and How Data Reviewed/Analyzed is Indicated in OP (Click thumbnail to enlarge image)

 Document Management Visit Info section of Note Couns/CoC section of Note Diagnostic Tests

Use the Mark Reviewed button. This now counts a re-review of the document if the date = today.

 Use the Independent Historian drop-down list of patient's Family Contacts or free-text field to document who is providing information to the provider.

Assisted by translator * checkbox to indicate a translator assisted the provider. 


* Feature Development Note:

- As of 11/24, this is under consideration by AMA as a valid MDM action and therefore will not be counted by OP at this time)

• Use the Discussed with field to select a name from Address Book or the patient's Clinical Contacts. Documentation of the discussion must also be entered into the Coordination of Care field.
• Use the Independent Interpretation of Tests checkbox to indicate such interpretation. Documentation of the interpretation must also be entered into the Coordination of Care field.
Use the Reviewed Today * button to indicate that a historical result was reviewed on the date of the Encounter, given it is relevant to the patient's current visit/reason for seeking care.

* Feature Development Notes:
- As of 11/24, the decision to exclude in-house tests was made by AMA, and OP plans to deliver the ability to filter these out in a future release.
- As of 11/30, the decision to exclude labs previously reviewed by you or another provider in the practice was made by the AMA, and OP plans to deliver the ability to filter these out in a future release.

Risk of Complications and/or Morbidity or Mortality of Patient Management

OP Can:

• Count Risk Assessment items eligible to be counted as a Social Determinants of Health (SDOH) that are marked pertinent for today's visit.

• Count when a provider issues a prescription with a linked NDC. The prescription needs to have one of the following status to be counted toward MDM:

- SENT

- PRINTED

- FAXED

- PICKED UP

- CALLED

- DELIVERED

- MAILED

OP Cannot:

Filter out ineligible OTC medications. The provider must decide whether or not to include an OTC medication when coding the Encounter.

• Default to an element level of Risk. The user must select or perform requirements for Moderate Risk calculation.

• Determine the complications of morbidity/mortality of patient management. For example, the decision to perform minor surgery and/or prescription management of chronic conditions. The provider must decide whether or not to adjust the Risk Level when coding the Encounter.

• Support calculating Minimal, Low, and/or High Risk levels

Where and How Risk of Complication is Indicated in OP (Click thumbnails to enlarge images)

Risk Assessment Editor
Risk Assessment in an Encounter
Use the SDOH checkbox to mark Risk questions as eligible for SDoH. By default, Food Insecurity, Health Literacy, and Housing Insecurity are selected.
Use the Pert (pertinent) checkbox to indicate which Risk Factors are pertinent to the visit.