One of the amazing benefits of a NAMAS membership is “Ask The Expert”. For this “Take”, I’m going to share one of the questions submitted to us by a NAMAS member, Carol, about emergency room leveling related around chest pain and high complexity.
So, Carol writes that the data column for most of their patients ends up being High due to the number of tests that are ordered to rule out any other complications. What we are trying to determine here is the difference in chest pain presenting in the emergency room when it is cardiac-related and the problem is unknown versus doing the workup and then sending the patient home because it is not cardiac-related. I feel the cardiac issue would be a level 5, and the other issue for chest pain would be a level 4. Again, Data having a hand in that. Remember that when we’re looking at our levels of service, under Medical Decision Making, we do have those three columns in the emergency room under MDM we look at. The first being the complexity of the condition. When a patient presents with chest pain of unknown origin, of course, we could consider that High Complexity depending upon how it is documented by the provider. The middle column may end up being High Complexity because of what is ordered. Remember, this level can’t be just because of what is ordered. Our order max is only Category One, and we will need more than just Category One to hit High Complexity. When looking at the middle column, it takes more than that, so make sure that it is not just orders that you’re using to get to High Complexity in that middle column. It would take something else, like discussing the issues with another provider, etc. So, make sure you’re really looking at column two to ensure that your Data is hitting High.
Now moving to that third column, I think this is going to be the difference maker in if this really is a level 5 or not, whether it’s emergency room, inpatient, or office. A lot of times in our notes, we’re seeing the physician’s failure to take the last Column in that treatment plan to the highest level it needs to. The last column is the Risk of managing that patient. It’s not just evaluating the treatment plan that was created by the provider. In our example above, If the patient is sent home because it was not a cardiac incident, that’s OK; that’s still part of the treatment plan. Having them follow up with say, the GI about GERD… those are treatment plans. But what is the RISK? What was the risk of treatment for that patient? What is the risk of ongoing patient management? All of that must be articulated by the treating physician for us to provide an analysis of that encounter. Without having that risk documented in conjunction with that encounter, we may miss out on being able to pull that encounter as a Level 5. It may absolutely support a lower level of service, maybe even as low as a Level 3. Remember, page 14 of the 2023 documentation guidelines state the evaluation and treatment should be likely in presentation to the nature and complexity of the presenting problem. Those should balance. So, this patient had chest complaints. They did have a lot of work up. Now that risk and management of that patient should also align with that high complexity if that patient truly is High complex. So, within MDM of the 2021 documentation guidelines for the 2023 expansion, what we’re trying to show is that all three columns are like a finely tuned instrument. They all work in sync. It doesn’t mean they all have to hit the same levels of High, Moderate, or Low. What it means is, if one is High, then they’re all kind of working in fine tune together. It always goes back to what is documented and how that complexity is demonstrated. There’s not a “yes it will” or “no it won’t” answer to Carol’s question, but rather really looking at the documentation of each one of these encounters to see which way the encounter takes you.
I hope this is helpful, and I hope you check out the benefits of a NAMAS membership and see if “Ask the Expert” would help you.
Your next steps:
- Become a NAMAS Member to earn those CEUs and take advantage of learning resources, products, and resources!
- Read more blog posts to stay updated on the 2023 Revisions to the 2021 E&M Guidelines.
- Watch the YouTube video of Shannon discussing this topic on the NAMAS YouTube channel and subscribe to get notified when new auditing and documentation tips drop.
- Check out the agenda for the 15th Annual NAMAS Auditing & Compliance Conference and register to attend!
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