Medical Decision Making (MDM) with the HGSA E&M Audit Worksheet
Quantifying medical decision making for E&M coding is only partly outlined in the 1997 Guidelines for E&M Services. The exact methods to quantify the number of diagnostic/treatment options and the data reviewed is not clearly defined in these Guidelines. To address this problem, several Medicare carriers have released audit tools with the method they accept for quantifying these parts of MDM.
The most common method used is the HGSA method, sometimes called the Highmark or Marshfield Clinic method. The major alternative is the Trailblazer method that must be used by healthcare providers in Texas, Virginia, Maryland, Delaware, and the District of Columbia. In general, it is easier to qualify for a higher level of MDM under the HGSA method.
What are E&M Services?
E&M services are easily recognizable medical services such as a visit to urgent care, hospital admission, or daily rounds on people admitted to a hospital. These services have multiple levels which correspond to different levels of medical complexity, such as a ‘new outpatient visit – level 4’. Selecting the correct level of service is critical to being paid appropriately for the patient encounter. Medicare released guidelines on how to select the proper service level in 1995 and 1997. These E&M Documentation Guidelines serve as the rulebook for E&M coding for physicians in the USA.
Not all medical services are covered under the 1997 E&M Guidelines. Surgeries, lab tests, preventative medicine, counseling, and imaging studies have separate documentation rules.
What needs to be documented for E&M services?
The 1997 E&M Guidelines state that each patient encounter must include a medical history, examination, and medical decision making (MDM). Each documentation component requires certain types of information to be documented in the medical record.
Documentation Components from the 1997 E&M Guidelines:
- Chief Complaint (CC)
- History of Present Illness (HPI)
- Past Family and Social History (PFSH)
- Review of Systems (ROS)
Medical Decision Making (MDM)
- The number of diagnosis or management options
- Amount and complexity of medical data reviewed
- Risk of significant complications, morbidity, or mortality