Making Sense of Medical Decision Making

A Strategy for Emergency Medicine

Woodrow Gandy, MD, FACEP

President, Emergency Services Consultants

Introduction

HCFA requires physicians to consider the complexity of medical decision-making in determining the level of service provided. HCFA specifies three major components in making this assessment: (1) risk level, (2) data assessed, and (3) scope of possible diagnoses or therapeutic options. For emergency department patients, two of these three components must meet or exceed the specified level to support a given level of decision-making.

These components arise from the character of the patient’s presenting problem and the quantity of data the physician assessed. HCFA and the AMA provide guidance in making this determination in several ways. The AMA/CPT manual’s example cases, listed after each level of service description, provide the most direct way to determine the level of decision-making. If a patient fits one of these examples and has an emergency department course typical for such a case, the coder may assign the corresponding level of decision-making.

Decision-making for problems not listed in the AMA/CPT Manual

For patients presenting with problems that are not listed among these examples, the coder must make an assessment of the complexity of decision-making. HCFA has provided guidance in the HCFA/AMA Documentation Guidelines and in a point scoring system released previously. Table I integrates the information from these two sources and from the AMA/CPT Manual.

Many coders find the assessment of risk and data to be the most straightforward components, but find it more difficult to assess the number of possible diagnoses and management options. Let’s examine this issue more closely. Which cases present a wider range of possible diagnoses and management options?

Number of Possible Diagnoses and Management Options

In making this determination, HCFA’s scoring system puts the heaviest weight on whether the patient is presenting with an "identified but undiagnosed" problem. An emergency department patient presenting for the first visit for a given chief complaint has an "undiagnosed" problem. The great majority of emergency department patients fall into this category. In contrast to the office setting, patients rarely come to emergency departments for scheduled visits for known problems.

When such an "identified but undiagnosed" problem requires "workup," the scoring system places the problem in the highest category in regard to the number of possible diagnoses and management options. The term "workup" generally implies more than a simple test such as a urinalysis. Most physicians use this term to refer to several tests, complex tests, or tests and consultation. This is also consistent with the wording in the HCFA/AMA Documentation Guidelines.

Many emergency department patients present with such "undiagnosed" problems requiring "workup." Hence, a patient presenting with a history of angina who makes an initial visit for worsening chest pain and requires "workup" (e.g., chest x-ray, EKG, and lab tests) would be in the highest category ("extensive") for the number of possible diagnoses and management options. The patient with a sprained ankle who requires an x-ray is an example of an "undiagnosed" problem that does not require workup, and would have fewer possible diagnoses and management options. HCFA’s guidelines and scoring system place this patient in the "multiple" category.

A Strategy for Determining Decision-Making

The following flow charts describe a strategy for assessing the level of decision-making. First, determine whether the patient is presenting with a problem listed among the CPT examples for various levels of service. If so, the complexity of decision-making supports that level of service. For example, a patient presenting for an initial visit for pelvic pain, who undergoes an evaluation including lab tests and pelvic exam, presents a medical decision-making complexity supporting CPT code 99284 (level four).

If the case is not listed, utilize the flow charts to make a determination. Determine first whether the patient presented with an "undiagnosed" problem and whether the case required "workup." Proceed to section A, B, or C on the basis of this determination.

Section A is for patients with "undiagnosed problems requiring workup," i.e. patients with "Extensive" possible diagnoses and management options. Section B is for patients with "undiagnosed problems not requiring workup." These patients fall into the "Multiple" category of diagnoses and management options. In section A, the coder "climbs the risk ladder or the data ladder." In section, B, the same concept applies but the "ladders" are "shorter."

Section C is for patients with return visits ("diagnosed" problems). It is important to remember that the question of whether a problem is "diagnosed" refers to the current episode of illness, not Past History. Hence, a patient with a history of angina who now presents with new (changed) chest pain has an "undiagnosed" problem. For return visits, it usually works best to assess risk and data first. If the coder can reach an acceptable level of service in this way, there will be no need to assess the number of possible diagnoses or management options. Return visits, typical of many office visits but less frequent in emergency departments, can be very simple or very complex. Use Table I to assess return visits.

Other Measures to Standardize Decision-Making Assessments

Physician groups can expand on the list of CPT example cases by developing their own internal lists of case scenarios. Using the method described above, a physician group can develop an extensive outline of common presenting problems and assign decision-making levels. This greatly speeds the process of coding and will standardize the assessment of decision-making within a physician group.

In assessing the level of medical decision-making, some CPT coders have relied on an "essay" in which the physician discusses the differential diagnosis and therapeutic options. This costly approach has several disadvantages. The physician may not receive credit for the actual complexity of the case when the coder is using this method. HCFA’s guidelines do not refer to such lists of differential diagnoses or discussion sections to determine the level of decision-making, but rather call for an objective assessment of the patient’s presenting problem. The criteria listed by HCFA are available from the history, physical exam, recorded data, and progress notes.

There is an additional hazard in relying on such essay sections to make complexity decisions. It is possible to dictate an extensive discussion section in a relatively simple case. Such "complexity upcoding" is readily apparent. The complexity of a case is not determined by the eloquence of the treating physician, but is a feature of the patient’s presenting problem.

Conclusion

Coders can enhance and streamline the process of coding through implementing procedures that approach medical decision-making in a disciplined, logical manner. The effort in establishing these systems will be rewarded by an efficient, effective coding process.

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