Making Definitive Decisions

June 14, 2011

How can I avoid an audit finding of "insufficient documentation" for medical decision making?

Question: Our physician was recently audited by one of our larger payers and had to pay back a good deal of money. The part she apparently did the worst on was the decision making piece - but all they said was "insufficient documentation for level." What are they looking for on level 5s for the high-level decision making? Even some of the 99214s were down-coded for this.

Answer: The exact answer to this question depends in part on which payer it is and what guidelines they use to measure medical decision making (MDM) - but most of them use the three table approach. To start, you should ask them for the criteria that your provider was evaluated against.

This is a big question, so here are the core elements of the answer. You need to communicate the complexity and/or severity of the problem(s).

For decision making to qualify for a 99215 on the first table you need to show them either:

• Two worsening chronic problems; or

• One worsening and two stable chronic problems; or

• One new problem with no further workup and one stable problem; or

• One new problem with further workup (diagnostic) planned.

For a 99215 on the third table, which you need to have in addition to the first table, you need to document:

• One chronic problem with severe exacerbation or side effect of treatment; or

• Several problems which are either worsening or stable but when taken together have the effect of creating the high risk situation; or

• Discuss a potential problem with high risk/morbidity/mortality that requires urgent rule out.
The best way to make this documentation visible is to enumerate the problems and make the status or potential threat of the problem clear. For individual problem status on 5s use the words severe, severely worsening or progressing, severe exacerbation, life threatening, seriously ill, gravely ill, significant functional impairment, etc. You can also say deteriorating, significant side effects of treatment, significant complications.

You can also make an overall statement that the patient is at high risk of morbidity or mortality "due to X." Rely on a statement like this only when the management of individual problems doesn't convey the sense of complexity involved with the overall management of the patient.

We don't want totally replicated, cloned comments about risk, but you need to deliver a sense of the overall patient acuity/complexity as necessary. Once any of these statements become too commonplace and prosaic they will lose impact. Only use them on the patients that need them.

Don't just say 'high risk,' specify 'high risk or M/M due to X.'

Remember that you can code either the 4s or the 5s by time if counseling or coordination of care dominates the encounter. We'll give you this same breakdown next month on the 99214s.

Bill Dacey, CPC, MBA, MHA, is principal in the Dacey Group, a consulting firm dedicated to coding, billing, documentation, and compliance concerns. Dacey is a PMCC-certified instructor and has been active in physician training for more than 20 years. He can be reached at billdacey@msn.com or editor@physicianspractice.com.

This article originally appeared in the March 2011 issue of Physicians Practice.