Scoring MDM in an E/M Note

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The 1995/1997 Documentation Guidelines are gone beginning 1-1-2023. (Ding dong….) However, we will still need to use them when auditing notes from before 2023.

This article does not apply to services performed after 1-1-2023.

Question:

I have a question about scoring MDM in an E/M note.  One of our coders thinks that if there is a new problem with labs ordered (new problem, work up planned) we can give four points under number of diagnoses, but we can’t count one point for lab.  She says that would be double dipping.  I disagree.  What do you think?

Answer:

I’m with you.  There are three components to MDM:

1. The number of diagnoses or management options,
2. the amount and/or complexity of date to be reviewed and
3. the risk of complications, and/or morbidity or mortality, the last better known as the table of risk.

Each is scored independently of the other two, and two of the three are required to select the level of MDM. There is no CPT^® or CMS guidance that says otherwise.

Continue giving new problem with work up planned four points in the number of diagnoses section, and one point in data.

In most cases, it probably wouldn’t make a difference in the level of E/M service selected, but we want to get it right.

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