Medical Decision Making

In a split/shared service, when a medical record includes a plan of care developed by the physician, based on a history and/or examination performed by the NPP and a personal review of diagnostic findings, would that statement, along with the physician’s signature, be enough for the MD or DO to be the substantive/billing provider?

Answer: If the MD or DO documents their personal development of the plan of care, as a result of their review of the NPP's work and the diagnostic results, and then signs the record, that would be sufficient to consider the MD/DO as the substantive provider. Please note that the record must clearly demonstrate the physicians role in the service as exceed that of the participating NPP.

In a split/shared service, when a physician’s note states they approve the PA/NP's documented plan of care and PA/NP's MDM, and the physician signs that record, is that sufficient documentation for the physician to bill as the substantive provider?

Answer: The MD or DO must personally develop the plan of care. When the documentation indicates that the NPP has developed the plan of care, the MD or DO’s indication of agreement with the plan is not adequate to support the MD or DO as the substantive provider.
Please define the criteria for MDM credit relative to drug therapy requiring intensive monitoring for toxicity.

Answer: Intensive monitoring for toxicity is required for drugs associated with significant potential for causing morbidity or death. Monitoring efforts are not related to assessment of therapeutic efficacy but are focused solely on assessment of adverse drug effects. Monitoring may be scheduled at the ordering provider’s discretion but must be done at least quarterly to qualify as “intensive.” Monitoring consists of diagnostic or laboratory testing; follow-up history and examination alone do not qualify as monitoring in this context. Testing must be directly related to the possible adverse effects of the drug; routine annual laboratory testing does not qualify as monitoring. A good example of monitoring for toxicity would be laboratory testing for cytopenia during a course of anti-neoplastic agent between dose cycles.
Please define the parameter for a decision to escalate hospital-level care when assessing MDM.

Answer: A decision to escalate the hospital level of care would include a decision to order observation services for an ED patient, or to have a patient admitted to inpatient status from either the ED or the observation service area. This might also include transfer of an ED, outpatient or inpatient to an ICU area.
What are the levels of MDM that may be assigned to an E/M service?

Answer: The four levels of MDM based on the 1995 and 1997 E/M guidelines remain unchanged and are: Straightforward, Low, Moderate and High.
How are each of the MDM levels now defined?

Answer: The MDM levels are defined as follows:
1. Straightforward – the E/M service has addressed a self-limited problem
2. Low- the E/M service has addressed a stable, uncomplicated, simple problem
3. Moderate- the E/M service has addressed multiple problems or the patient is significantly ill with a singular problem
4. High- the E/M service has addressed singular or multiple problems for a patient who is very ill
Please define how the amount and/or complexity of reviewed and analysis impact the level of MDM?

Answer: These factors impact the MDM level as follows:
1. Straightforward- review and analysis of data is minimal or none
2. Low- two documents are reviewed and analyzed or the provider elicits history from an independent historian, due to the patient’s inability to provide history
3. Moderate- select one of the following scenarios:
  1. the provider reviews two documents and elicits history from an independent historian
  2. the provider interprets document(s) prepared by another provider(s), e.g., diagnostic reports
  3. the provider confers with another provider relative to the patient’s problem
4. High- same concepts as at the Moderate level but applied to two of the scenarios defined above
Please define the risk of complications and/or morbidity and/or mortality assigned?

Answer: Risk is assigned relative to each of the levels as follows:
1. Straightforward- no treatment is prescribed or there is minimal risk associated with the prescribed treatment or testing plan
2. Low- problem(s) are associated with low risk and require minimal discussion and/or patient consent
3. Moderate- the provider would review a moderately serious problem with the patient/surrogate, obtain necessary consent and monitor the outcome of the treatment plan. This would also apply in situations where complex social factors may impact patient management
4. High- the provider would discuss potential higher risk problems that will require ongoing monitoring
Please define a self-limited or minor problem.

Answer: A self-limited or minor problem is one that runs a definite and prescribed course, is transient in nature, and is not likely to permanently alter health status.
Please define a stable, chronic illness.

Answer: A stable, chronic illness is a problem with an expected duration of at least a year or until the death of the patient. Conditions are treated as chronic even when stage or severity changes (e.g., diabetes is a chronic condition, whether it is controlled or uncontrolled). The term “stable” is based on meeting treatment goals; when goals are not being met, the condition is not considered to be stable and the provider’s effort(s) toward enhancing stability are calculated into the level of MDM.
Please define an acute, uncomplicated illness or injury.

Answer: This is a recent or new short-term problem, associated with a low level of risk of morbidity and for which treatment is considered. Full recovery without functional impairment is expected. A problem that is usually self-limited but remains unresponsive to treatment may be considered an acute uncomplicated illness.
Please define the categories into which data is divided for review and analysis.

Answer: There are three categories into which data is divided:
1. Each test, document, order or independent historian is counted to meet a threshold number
2. Independent interpretation of tests not reported separately
3. Discussion of management or test interpretation with an external physician or QHP appropriate source, not reported separately
Please define the risk of complications/morbidity/mortality as included in patient management?

Answer: Risk includes all management options relative to the patient’s problem, both those selected during the visit and those that have been considered but not selected. In addition, risk includes adverse factors associated with social determinants of health.
Please define prescription drug management relative to MDM.

Answer: In order to count prescription drug management there must be documentation of at least one of the following factors:
1. A prescription drug that the practitioner is evaluating the appropriateness of using for the patient; and/or continuing to prescribe for the patient.
2. Documentation on the prescription drug(s) that are being considered and the reason why they are being considered.
3. Documentation of a decision to initiate a new prescription drug(s).
4. Documentation of a practitioner’s decision to discontinue a prescription drug or to adjust the current dosage relative to changes in a patient’s condition.
5. The patient condition, possible adverse effects, potential benefits, etc. of the patient using this prescription drug.

Prescription drug management is based on the documented evidence that the provider has evaluated medications during the E/M service as it relates to the patient’s current condition. Simply listing medications that patient takes is not prescription drug management. Credit will be provided for prescription drug management as long as the documentation clearly shows decision-making took place in regard to those medications.

Please define the circumstances in which a provider may take MDM credit for ordering and reviewing diagnostic tests.

Answer: When a provider orders a diagnostic test that will be performed, interpreted, and billed:

By a different provider, the ordering provider may take credit for ordering the test or reviewing the results during the visit (e.g., chest X-ray, CPT 71046).
By his/her office or group, then no credit may be allowed for the order or review in the MDM component of the visit. This is because reimbursement for the interpretation of the test is included in the fee for the diagnostic service (e.g., EKG, CPT 93000).
By his/her office or group, but does not require or include separate interpretation, the ordering provider may take credit for ordering and reviewing the test during the visit (e.g., CBC, CPT 85025).

Reviewed 10/8/2024