Medical Decision Making (MDM) with the Trailblazer E&M Audit Tool
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 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 used in the rest of the USA.
Healthcare providers in Texas, Virginia, Maryland, Delaware, and the District of Columbia must use the Trailblazer method for MDM determination. In general, it is more difficult to qualify for a higher MDM level under the Trailblazer rules.
Download the official Trailblazer E&M audit tool as a PDF
The Medicare Evaluation and Management (E&M, E/M, or E M depending on your preference) Coding cheat sheet has scoring tools for the history, exam, and medical decision making elements that are required for all E&M encounters. This worksheet includes the scoring tools outlined in the 1995 and 1997 Documentation Guidelines for Evaluation and Management Services published by CMS.
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 E&M Documentation 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 Documentation 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 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