December 15, 2023 | By Stephanie Allard, CPC, CEMA, RHIT
One area that keeps coming up in my conversations and education sessions is the definition and understanding, or misunderstanding, of the concept of a “problem addressed” during an encounter and how that is applied to E/M services.
As treating practitioners document and as we work through the coding/auditing process, we need to keep in the forefront of our thoughts that a problem is not considered to be addressed based on the fact alone that the patient has the condition. Instead, we must see the documentation specifically identify how each of the individual diagnoses were evaluated and assessed as a part of the assessment and decisions made during the visit.
In my experience, when reviewing encounters in the hospital setting, there have been many variances due to patients’ active conditions automatically being attributed to each individual specialist just because they are present during the hospital stay. I often find that the treating practitioner wants to bill a level 3 subsequent visit 99233 based on High Medical Decision-Making (MDM). This has been problematic as notes often state what the other specialists are doing to manage the various diagnoses and do not show how the treating practitioner assessed, managed, or had to consider all the conditions/symptoms when making their personal decisions.
In the office setting I am finding multiple variances, but the acute visits stand out to me. When a patient presents for management of an acute infection, the fact that the patient has chronic conditions alone does not automatically increase the level of complexity of the presenting problems if the note only lists the conditions. I am finding that a level 4 E/M service is being selected based on the chronic conditions being present. In this scenario, we would need to see documentation showing how the conditions impacted decisions made or complicated the patient’s status or treatment of the acute problem.
For me, it helps to pull the AMA definition of a “problem addressed” and look to their root explanation as to how we are applying this to the diagnoses that we are considering as a part of leveling of MDM. AMA provides us with the following definition:
►Problem addressed: A problem is addressed or managed when it is evaluated or treated at the encounter by the physician or other qualified health care professional reporting the service. This includes consideration of further testing or treatment that may not be elected by virtue of risk/benefit analysis or patient/parent/guardian/surrogate choice. Notation in the patient’s medical record that another professional is managing the problem without additional assessment or care coordination documented does not qualify as being addressed or managed by the physician or other qualified health care professional reporting the service. Referral without evaluation (by history, examination, or diagnostic study[ies]) or consideration of treatment does not qualify as being addressed or managed by the physician or other qualified health care professional reporting the service. For hospital inpatient and observation care services, the problem addressed is the problem status on the date of the encounter, which may be significantly different than on admission. It is the problem being managed or co-managed by the reporting physician or other qualified healthcare professional and may not be the cause of admission or continued stay.
Notice in this definition, there is a reference to the diagnoses being considered as addressed if the note is showing us what the provider personally did to either monitor and/or treat each individual condition/symptom. We cannot consider a problem being personally addressed during the encounter just because the patient has it or another provider is managing that for them. We instead must see how decisions made during the encounter were impacted by the fact that the patent has the symptom/condition.
Over the years, I have found that some of the misunderstanding stems from the way EMR systems tend to be used when the documentation is created. What I mean by that, is an “Assessment” has morphed into more of an ongoing problem list instead of the status of the conditions according to the treating practitioner, which then ties into an active treatment plan. This has resulted in the final product of documentation not always clearly identifying the specific diagnoses that were a part of the decision-making thought process. This is an area that we need to consider during our audit reviews to help prompt change through education with our providers.
As we continue to work through the nuances of the guidelines, I encourage you to have open conversations regarding the definitions we now have from AMA. If you are to look at the surface level at the MDM grid you will find short statements about each of the areas we are to consider when leveling an E/M service. Do not forget that we have over 40 pages of guidance from AMA that is full of definitions and further explanations. Also, remember that we need to look to CMS and the payers as they reimburse the claims. Medicare Contractors have entire sections of their websites dedicated to E/M services that also offer further clarification.
Your next steps:
- Challenge what you are being taught by organizations that contradict the guidelines, and ask the instructor for site and source references
- Read more blog posts to stay updated, especially as we journey into 2024
- Check out the NAMAS Membership opportunities that provide up to weekly educational opportunities for you and your team
NAMAS is a division of DoctorsManagement, LLC, a leading medical consulting firm since 1956. With experienced auditors boasting CPC and CPMA certification and 10+ years of experience, NAMAS offers comprehensive auditing education, resources, and services. Our team has educated DOJ, RAC, CMS, and Medicare Advantage auditors, as well as hospital and physician-based professionals. We take pride in helping individuals excel in auditing and compliance.
