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Moving to Medical Decision-Making as the Key Component

Office billing is now based solely on either MDM or total time.

Last week, I declared that it is my opinion that medical decision-making (MDM) should always be one of the components that contributes to selecting (or perhaps, demonstrating) the appropriate level of service (LOS) for the professional fee. In January 2021, MDM became the only component determinant of office or other outpatient evaluation and management (E&M) services. Office billing is now based solely on either MDM or total time. It is rumored that by January 2023, many other E&M services are going to follow suit.

The American Medical Association (AMA) has announced its intent to delete and revise many codes (February 2021: CPT® Editorial Summary of Panel Actions (, but it is keeping the precise nature of the revisions under wraps. Code sets that will be affected include inpatient and observation care services, consultations (a code set that is not utilized universally), emergency department services, and nursing facility services.

If they are going to MDM-defined LOS, are the guidelines and definitions going to be identical to the office-based ones? I do not know for certain, but the ones they have set out for office E&M services are reasonable and seem generalizable. I don’t think the AMA is likely to redefine the nature of problems; data is data, and the risk of complications and/or morbidity or mortality of patient management is likely to be transferrable. Historically, they try to keep things somewhat standardized, if not identical, across all services.

There is a tool called the Marshfield Audit that has been used for assessing the complexity of MDM, and it is still utilized to judge non-office-based E&M code selection. It is not sanctioned by the Centers for Medicare & Medicaid Services (CMS), but it is used by many auditors to help non-clinician auditors assess the complexity of MDM by clinicians.

AMA has supplied us with a tool to help level-set office-based E&M codes now (, and I predict it will be used more generally after the great E&M revision. Each tool has three factors that are considered when selecting complexity of MDM.

I think comparing and contrasting them will be useful. Let’s start here:

Marshfield: Number of Diagnoses or Management Options

  • Self-limited or minor problem(s)
  • Established diagnosis – improved, well-controlled, resolving, or resolved
  • Established diagnosis – inadequately controlled, worsening, or failing to change as expected
  • New Problem – No additional workup planned
  • New Problem – Additional workup planned

AMA: Number and Complexity of Problems Addressed

  • Self-limited or minor problem(s) [1 – minimal; 2 or more – low]
  • Stable chronic illness(es) [1 – low; 2 or more – moderate]
  • Acute, uncomplicated illness(es) or injury(ies) [low]
  • Chronic illness(es) with exacerbation, progression, or side effect of treatment [moderate]
  • Undiagnosed new problem(s) with uncertain prognosis [moderate]
  • Acute illness(es) with systemic symptoms [moderate]
  • Acute complicated injury(ies) [moderate]
  • Chronic illness(es) with severe exacerbation, progression, or side effect of treatment [high]
  • Acute or chronic illness(es) or injury(ies) that pose(s) a threat to life or bodily function [high]

The AMA version is an amalgam of the Marshfield’s diagnoses or management options and its presenting problem from the risk component. The CPT manual notes that the presenting symptoms may drive the complexity of medical decision-making even if, in the final analysis, it turns out that the final condition is not highly morbid. It also notes that having multiple problems can increase the complexity of MDM. Examples of each type of problem can be found in the CPT Evaluation and Management Office Guideline Changes (

Hence, the AMA version is more explicit about the effect having two or more minor problems or stable chronic illnesses has on the MDM (it jumps the complexity up a notch) component. It also calls out the fact that the problems need to be addressed. This means just having a chronic condition isn’t sufficient; the provider needs to demonstrate that there is MEAT or TAMPER involved (those acronyms’ components include monitoring, measuring, medicating, evaluating, assessing, planning, referring, treating) with that condition. This is an area of opportunity for documentation improvement.

In fact, the converse is probably more impactful – there are problems, illnesses, or injuries that are being addressed, but they aren’t counted, because the provider didn’t take the time to document them as diagnoses or mention them in the MDM section. We need to train providers to take credit for the work they are doing.

The Marshfield tool has a section for the amount/complexity of data, and it includes a point for reviewing and/or ordering of clinical tests, radiological studies, and other tests like EEG, EKG, cardiac catheterization, vascular studies, and pulmonary function tests. The provider gets another point for discussing the tests with the performing physician, independently reviewing images/tracings/specimens, and then another point each for obtaining history or old records and then their review and summarization.

This always stuck in my craw – you get the same credit for looking at a single complete blood count (CBC) as for a whole panel of laboratory studies, or doing a single AP chest X-ray versus a head, neck, chest, and abdominal CT scan. The complexity should increase with the amount of data, in my mind.

The AMA tool takes that to heart. Each external document or test result reviewed and each unique test ordered is counted. If a patient has a CBC, comprehensive metabolic panel (CMP), and a troponin, that is counted as three points. Utilization of an independent historian, independent interpretation of a test performed by someone else, or discussion with someone else who is either helping manage the patient (e.g., a consultant) or someone who performed a test or procedure counts as additional data.

The final element in selecting the level of MDM is risk. For Marshfield, this was divided into three subcategories: presenting problem, diagnostic procedure/s, and management option/s. The highest level defines the level of risk.

  • Presenting problems incorporated the detail now found in the AMA’s Number and Complexity of Problems Addressed. The four levels are minimal, low, moderate, and high, and it escalates with chronicity, complication, and how much of a threat to life or bodily function is posed.
  • Diagnostic procedure/s has the same four levels, and there is increasing invasiveness and risk factors as the levels mount. Obtaining fluid from body cavities is moderate, and diagnostic endoscopy or cardiovascular imaging with contrast and identified risk factors is high.
  • Management options again range from minimal to high. Over-the-counter drugs and straight IV fluids are of low risk, whereas IV fluid additives and prescription drug management are included in moderate risk. If parenteral controlled substances are utilized, the risk is high. Elective major surgery without identifiable risk factors is only moderate, whereas risk factors for emergency (as opposed to elective status) is deemed high.

The AMA MDM risk assessment is titled “Risk of Complications and/or Morbidity or Mortality of Patient Management.” It combines the three risk components of the Marshfield tool into a single table that considers the risk of morbidity from the testing, treatment, or procedure (as opposed to the condition itself). There are a few elements I would call out:

  • Prescription drug management is still leveled at moderate. For the office-based crowd, the key word is “management.” The provider needs to be making a decision about the medication – should I increase the dosage, leave it the same, decrease it, or discontinue it? Not just “see med list.”
  • “Diagnosis or treatment significantly limited by social determinants of health (SDoH)” defines a moderate risk. This emphasizes the impact of the SDoH. Is the patient homeless or illiterate? Document it. Providers will need to be coached into making SDoH diagnoses.
  • Decisions regarding hospitalization are of high risk. In the ED, this is straightforward; however, it will be interesting to see what will correlate to this when MDM regarding hospitalized patients (inpatient/OBS) transitions to being the sole billing component.
  • The decision not to resuscitate or to deescalate care because of poor prognosis is weighted as high risk, the same as resuscitation (i.e., high risk of morbidity from treatment).

I believe that providers often undervalue and unintentionally down-code their services. If MDM becomes the sole component for E&M LOS, the well-versed provider may find their LOS increasing. In my opinion, the AMA matrix correlates well with the level of MDM that clinicians are currently performing.

Now, if we can only get them to put mentation into their documentation, so everyone can tell they are doing it! My advice is, follow the rubric.

Programming Note: Listen to Dr. Remer every Tuesday when she cohosts Talk Ten Tuesdays with Chuck Buck at 10 Eastern.

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Erica E. Remer, MD, CCDS

Erica Remer, MD, FACEP, CCDS, has a unique perspective as a practicing emergency physician for 25 years, with extensive coding, CDI, and ICD-10 expertise. As physician advisor for University Hospitals Health System in Cleveland, Ohio for four years, she trained 2,700 providers in ICD-10, closed hundreds of queries, fought numerous DRG clinical determination and medical necessity denials, and educated CDI specialists and healthcare providers with engaging, case-based presentations. She transitioned to independent consulting in July 2016. Dr. Remer is a member of the ICD10monitor editorial board and is the co-host on the popular Talk Ten Tuesdays weekly, live Internet radio broadcasts.

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