A Moving Target

January 1, 2006

Expert Bill Dacey helps you navigate the shifting E&M rules.


After some years of relative peace in the arena of E&M coding and documentation, all hell is breaking loose. The rules are shifting.

As you know, physicians are supposed to select an E&M level based on the complexity of three factors: the history, the physical, and the medical decision making.

It's the rules associated with determining the difficulty of that last factor that is suddenly a matter of discussion.

The original set of decision-making tables provided by CMS contains a point system much like those in the history and examination components. You determined the medical decision-making difficulty by seeing if two of three components met or exceeded the definitions of that level of decision making within the tables.

This table has always had some issues: Is the "new problem" new to the patient or to the examiner? What is meant by "additional work-up"? However, most practices, and even most payers, regulators, and auditors have been forced over the years to come up with some definition of these terms and code and document accordingly. There was an uneasy consensus.

Until now.

A Change in Season

In September 2005, Deborah Patterson, MD, medical director at Trailblazer, the Medicare carrier in several large states, offered a new interpretation of the MDM table. In fact, it was more of a complete rewrite of the table.

According to Patterson this is the first time that Trailblazer has shared how they review the diagnosis and management section. It goes something like this:

  • No points given for new or established problems with non-evaluation or management mentioned if it is not clearly a comorbid condition.

  • A new or established problem with no evaluation or management mentioned and the problem is a comorbid condition - 1 point.

  • A new or established problem with evaluation or management mentioned - 1 point each.

  • No points for treatment option notations such as continue "same" therapy or "no change" in therapy (including drug management) without further description.

  • Continue "same" therapy or "no change" in therapy without further description or scheduled monitoring without specific therapy - 1 point.

  • Drug management, new prescriptions or changes in dosing for current medications - 1 point.

  • Complex drug management (more than three medications/prescriptions and/or over-the-counter), new prescriptions or changes in dosing for current medication - 2 points.

  • Open or percutaneous therapeutic cardiac, surgical, or radiological procedure, minor or major - 1 point.

  • Physical, occupation, or speech therapy or other manipulation - 1 point.

  • Closed treatment for fracture or dislocation - 1 point.

  • IV fluids - 1 point.

  • Complex insulin prescription (SC or combo or SC/IV), hyperalmentation, insulin drip or other complex IV admix prescription - 2 points.

  • Conservative measures such as rest, ice, bandages, dietary - 1 point.

  • Radiation therapy - 1 point.

  • IM injection/aspiration or other pain management procedure - 1 point.

  • Patient education on self or home care topics/techniques - 1 point.

  • Hospital admission - 1 point.

  • Hospital admission, other physician(s) contacted - 2 points.

  • Referral to another physician, consultation - 1 point.

There's more. Once you add up all of your new points - or lack thereof - instead of using the four-point table that CMS put in place more than 10 years ago to determine complexity, Trailblazer has created a new gradient:

  • Less than or equal to 2 points - Minimal

  • 3-4 points - Multiple (low)

  • 5-6 points - Multiple (moderate)

  • 7 or more points - Extensive

The issues involved here are significant. Since the guidelines first appeared in 1994, providers have been working to master both coding and documentation, and, I think, have slowly improved over time. In part this is due to consistency; the rules haven't changed much in that time.

Now we have one of many Medicare carriers exercising a considerable amount of autonomy in the application of a federal program. No doubt some will question the legality of this. We now have glaring differences in how the most critical component of E&M codes is determined, depending on the carrier.

AMA on the Move

You might expect such interpetation from the carrier or payer side of the equation. But, now, the physician side is adding to the mix, too.

As a refresher, apart from the key components of history, examination, and medical decision most often used to select the appropriate level of service code, there are also four remaining components called "contributory components" - counseling, coordination of care, time, and nature of presenting problem.

Stephen R. Levinson, MD, an author and influential voice within the AMA on coding, has created yet another table to consider when determining the correct level with respect to the nature of the presenting problem.

Not much has been said in recent years about this - and there's a reason for that. It's already built into the MDM table.


The MDM table contains a gradient of the number of problems and some indicator of the stability or familiarity of the problem.

So what's the upshot of all this? Well, at least one carrier has taken it's own direction as regards 'interpretation' of decision making elements. Levinson, with some AMA support, has proposed his reiteration of the 'risk-driven' coding and documentation approach - a quite useful approach by the way. And CMS, the progenitor of the original guidelines, has remained silent.

It has always been a curiosity - the AMA owns the codes, but has never provided detailed guidance as to their actual application. The Feds have attempted over time to provide the guidance, which is now being ignored by their own contractors (carriers). Where is the actual governance to come from? How about a decision as regards decision-making?

It's completely unclear. And you thought E&M coding was tough before.

Bill Dacey 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 over 10 years. He can be reached at billdacey@msn.com or via editor@physicianspractice.com.

This article originally appeared in the January 2006 issue of Physicians Practice.