A Tool to Help Set Evaluation and Management (E&M) Levels of Service

I am the Co-Director of the Intensive Course in Medical Documentation: Clinical, Legal and Economic Implications for Healthcare Providers. It is a course created to remediate folks who had gotten in trouble with their medical boards, but nowadays about 20 percent of attendees are not mandated, but choose to take it.

I have two lawyers who address topics like fraud, abuse, informed consent, responsible use of social media, and malpractice. A faculty member who touts herself as a capitalist corporate compliance officer teaches providers how to use Evaluation and Management (E&M) codes and how to appropriately level visits. My Co-Course Director is a well-known addiction specialist, and discusses controlled substances. And I address putting “mentation” into clinical documentation.

Although many topics stay constant, I try to keep the material fresh and relevant. On Jan. 1, 2023, hospitals and other care facilities joined outpatient settings in strictly using medical decision-making (MDM) or time to set the level for E&M services. Historically, providers used a combination of history, physical examination, and complexity of medical decision-making to determine level of service. I always espoused using MDM as one of the components.

This time around, I discovered a great resource: AMA’s Simplified Outpatient Documentation and Coding toolkit. The last section of this toolkit has clinical vignettes that are assessed for the level of service and why each conclusion could be drawn. I loved the concept, and contacted the American Medical Association (AMA) to see if I could use them. They gave me permission, but I decided to find our own examples while following their lead.

I made another change. They set the level, say Level 4 (99214) and then showed why they picked that, for instance: > 2 stable chronic conditions and prescription medication management constituting moderate in 2 out of 3 elements.

I decided it would be more valuable to have all the elements of all the strata (e.g., straightforward, low, moderate, and high) available to peruse when determining the level of each of the three elements of MDM. To that end, I created a worksheet which you can see here and can be found for download on my website, icd10md.com (under Free pointers -> CDI tips)

Here is an example of the exercise:

We often talk about whether there should be more detail to the medically appropriate history. Are the diagnoses all codable? Are they in the right order? Does this constitute prescription drug management?

I show them my revised documentation:

And then we review the MDM elements and see how this should be leveled as a 99214:

If you think this would be helpful to your providers, feel free to share it with them, use it with them, or hand it off to a physician leader or a professional billing professional who might be able to utilize it. It is designed for outpatient providers, but can easily be adapted to help guide inpatient providers, too.

I have an entire module on MDM in Dr. Remer’s Documentation Modules. Have your providers check them out, too, and see if they could be another tool in your education toolkit.