April 4, 2022 | By Shannon DeConda, CPC, CEMC, CEMA, CPMA, CRTT
Today, I want to bring you a little educational tidbit on E&M documentation improvement and how to audit those challenging sections of E&M. We’re going to take a look at the third column of our MDM table, the Risk of Complications for Patient Management and treatment.
What I want to specifically point to is the risk of the management and treatment. Under this column, there are examples that are listed here that the AMA has provided, and we know there are a lot of different treatment options and treatment plans that do occur within the everyday patient encounter that aren’t on here, and honestly, that’s what we get a lot of questions about here at NAMAS. One of those questions is about consults and referrals. Not consults and referrals that come into the provider, but rather those consults and referrals that go outbound from the patient encounter.
So, here’s an example: Our provider sees a patient today, and during that encounter, the decision is made to send the patient for a consult to another provider. Now, when we review our 3rd column of the MDM table, there’s no place that just jumps out and says “Choose Me!” for a consult or referral. Let’s go back to what the title of this column is: Risk of Treatment or Management. Meaning, how much risk is associated with sending the patient for a consult…not much, right? However, we also get to give our providers credit under 2021 documentation guidelines, risk associated with considered treatments (on page 6 of the original 2021 documentation guidelines). This specifically talks to this particular treatment and management option. So, if our provider is, for example, an internal medicine provider/family practitioner who has been following a patient that has chronic pain, the patient has been given chronic pain management medications and it’s been long enough that this patient now needs to be referred to a pain management clinic for further follow-up. We know that patient is going for long-term pain management. If the provider writes the note to say “consult to pain management” or “referral to pain management” or “transfer to pain management”, that’s very little to go on for the risk of treatment plan, and it’s not much by way of risk. However, instead, if the treatment plan is written to say that if the risk of the treatment management is the ongoing risk of managing of the consult to manage that patient through prescription drug management, that now shows the risk in the category of risk to better allocate that problem.
What about a patient that is seen by a provider, and they can very easily identify that this patient has the need for consideration for decision of surgery by another provider? That consideration, those treatment recommendations, if written appropriately could have that complexity. Now, that’s not going to be our sole determining factor in determining the overall level of service for that particular encounter. But it could play a part.
Educating our physicians to write those consult referrals and transfers of care more effectively can help us better understand how to allocate the levels of risk for those particular encounters.