Medical Decision Making (MDM)
Next is determining the level of the physician’s medical decision making (MDM). TheMDM refers to the level of risk and difficulty involved in the diagnosing, treatment,and medical planning that is involved in an EM visit. The MDM may be straightforward, low complexity, moderate complexity or high complexity. See Chart 3:Decision Making (RISK table)SF: Straight Forward
Minimal 1Minimal 1Minimal 1
LC: Low Complexity
Limited 2Limited 2Low
Multiple 3Multiple 3Moderate
HC: High Complexity
Extensive >4Extensive >4High
Time is a “time” component of the EM codes. However, time does not takeprecedence of appropriate documentation of the history, physical and medicaldecision making. If a physician documents a comprehensive EM service is less thanthe time allotted, he still may charge for the comprehensive service. Similarly, if thephysician takes more time than allotted to document the same comprehensive visit,he may still only charge according to the document elements of the visit. The onlyexception to this is with counseling and coordination of care. Some E/M is timedependant like critical care and in this specific case the exact time spent must bedocumented. See Critical care section below.
Counseling, and/or Coordination of Care
When counseling and/or coordination of care comprises more than 50% of the timespent during an EM visit, then time may be considered the key or controlling factor toqualify for a particular level of E/M service. However, several criteria must be met.First, the physician’s “time” must be spent “face–to-face” with either the patient orthe patient’s family. For inpatient, if the physician is just on the hospital unit floorcharting and doing other tasks, which are not face-to-face with the patient orpatient’s family, then this time does not count towards the EM service. Second, thecounseling must be fully documented, e.g., what was said, done, planned and soforth. Third, time should be documented. If this is a time-driven EM, then start timeand stop times for the face-to-face encounter should be documented in the PHR.
Key #6 Choosing an EM Level
Now we will summarize the documented history, physical exam and medical decisionmaking and choose a level of EM. Here are several scenarios of EM for new andestablished patients. Remember when choosing an level, a new EM service requiresall 3 components to be at the highest level in order to choose that particular code,versus an established EM service only requires 2 out of 3 to choose a level.