Medical decision-making (MDM) mistakes are common. Identifying elements of medical decision making (MDM) and medical necessity are the foundation of emergency medicine coding. Comprehending these elements also provides valuable information on how well or how poorly other critical elements of a medical chart are documented.
Here are some common coding and documentation mistakes hospitals usually make:
1. Documentation
If it’s not documented, it was not done! Appropriate documentation for every service date helps to convey patient complexity during a medical record review. Remember, auditor only reviews the service date in question, not the entire medical record. The hospital staff should be able to formulate a complete and accurate description of the patient’s condition with a parallel plan of care for each encwounter. Listing problems without a equivalent plan of care does not validate physician management of that problem and could cause a downgrade of complexity. Physician documentation should always include all problems addressed during each encounter. It should spot problems as stable or progressing, indicate differential diagnoses when the problem remains undefined, and should mention the follow-up management/treatment options for each problem.
2. Relevant Data
Keeping relevant “documents” that contributes to diagnosing or managing patient problems solves half of the problem. Relevant orders or results may appear in the medical record, but many times the communications involving testing are undetected when reviewing the progress note. It’s important to specify tests ordered and rationale in the physician’s progress note.
3. Complexities of the Patient’s Condition
Physicians often undervalue their services because they do not understand the MDM component of the documentation guidelines. For instance, a lot of physicians consider a case to be of low complexity because of the frequency with which they encounter the case type. Though, the frequency with which the care plan is developed should have no bearing on how complex the patient’s condition really is. Patient risk is categorized as minimal, low, moderate, or high based on pre-assigned items relating to the presenting problem, diagnostic procedures ordered, and management options selected.
Medical decision-making is one of three components in evaluation and management (E&M) services, along with history and exam. In this upcoming session on Medical Decision Making for the Emergency Department, expert speaker Caral Edelberg will dissect the medical decision making components of a medical record and present thoughtful insights to assist coding professionals and providers in understanding how risk factors, interventions, and diagnosis define levels of medical decision making in the emergency department.
