The crucial elements in the determination of medical necessity via communicating complex conditions properly
As we all know, not every case that comes into our office is the same. Some instances have fewer complicating factors and multiple region involvement than others. We should not document and code every case the same for the same reason. Changes in the Evaluation and Management (E/M) and ICD-10 codes have made communicating complex conditions easier for the practitioner.
Recent coding changes
The CPT E/M services guidelines underwent a significant overhaul as of Jan. 1, 2021. Previously, the Centers for Medicare and Medicaid Services guidelines for 1995 and 1997 were sometimes not applicable to the chiropractic profession and often confusing.
In the 2021 E/M guidelines, providers are given a choice of medical decision-making (MDM) or time as the primary element. No longer are we tasked with documenting unnecessary details to satisfy E/M requirements. Now the provider is given a choice to examine and document medically necessary information to establish a diagnosis, assess the status of a condition, and select the appropriate treatment option.
Likewise, the International Classification of Diseases (ICD) has become even more specific since the release of the ICD-10 coding system in 2015. With over 72,000 as of Oct. 1, 2021, the ability for the provider to specifically communicate the diagnosis to a third party has become easier and attainable. The complexity of an evaluation and management of a case must be compatible with the specificity and complexity of the diagnosis. Long gone are the days of cervicalgia and lumbalgia diagnoses. In fact, the diagnosis of lumbalgia (M54.5) was deleted as of Oct. 1, 2021, and was replaced by more specific diagnoses.
Evaluation and management
E/M time-based coding includes face-to-face and non-face-to-face services as long as they are done on the same day of the encounter. Time-based coding may put the experienced provider at a disadvantage, as an experienced provider may do the same amount of work in less time than a less experienced provider. In this case, the skilled provider should not be punished just because they are more efficient in communicating complex conditions.
Therefore, in many cases, medical decision-making would be chosen as the method to determine the proper choice of E/M CPT code.
When choosing the MDM guidelines for the E/M CPT code, a provider must consider three categories to determine the level of complexity:
- Diagnoses, conditions or problems being treated or taken into account (addressed) pertaining to the chief complaints.
- The amount and complexity of the data ordered, reviewed and analyzed on the day of the encounter.
- Risk, comorbidity, or complicating factors that must be considered when ordering tests or in treatment options.
For example, suppose a patient presents with low-back pain, related leg pain, and plantar fasciitis caused by hyperpronation of the feet, causing an abnormal gait. In that case, this represents several factors that must be addressed in the treatment options for the patient.
If the patient also has systemic problems, such as bowel or bladder dysfunction and diabetes, this will further complicate the patient’s treatment. Current patients may also have preexisting conditions such as a recent COVID infection causing fatigue, joint pain, muscle weakness and loss of equilibrium.
Complex conditions, X-rays and foot scanning
Additionally, if the provider conducts an examination and decides X-rays are to be taken due to the presenting condition, the ordering and analysis of the X-rays or the report would be considered in the complexity of the data to be reviewed and analyzed. Since the plantar fasciitis and equilibrium changes alter the gait, the use of a 3-D kiosk foot scanner would be ordered and analyzed to determine the objective cause of the plantar fasciitis and the treatment options such as custom-molded orthotics.
Furthermore, the ordering and prescribing of the proper custom orthotics would also be documented in the medical decision-making. Thus, a foot scan is indicated and yields important objective information to determine the cause of the problem and the ideal treatment. As one can imagine, this scenario is commonplace in the chiropractic office, yet infrequently documented.
The risk of causing death or complicating conditions when ordering tests or treating the patient in a chiropractic office is extremely low. Therefore, in considering the three categories of data, the lowest common denominator of the complexity of two data elements is used to determine the level of E/M complexity.
Once all the data is documented, analyzed and decided upon, the nature of the mechanism of injury, the treatment options and the diagnoses are documented. If all of these factors are reasonably related in complexity and rationale, the care is considered to be medically necessary. When one factor does not relate to another in communicating complex conditions, the third party will deem the process not medically necessary.
The specificity of coding
Your diagnosis is a crucial element in the determination of medical necessity. A basic rule of diagnosis coding is to code what you know to the highest degree of specificity. If a complicating factor exists, this should also be coded and placed in the last position of your diagnosis list.
For example, if the patient has back pain and sciatica due to an altered gait from plantar fasciitis, you would diagnose sciatica (M54.41, M54.42) and plantar fasciitis (M72.2). Although an altered gait is present, you would not necessarily code the altered gait because some may consider the gait to be a symptom of the other conditions.
The MDM level exists to identify the complexity of arriving at the diagnoses and aid in the treatment plan. By determining the possible causes and, therefore, how to proceed with treatment, the physician treats the symptoms of the condition and the cause of the disorder.
The ordering, analysis and application of the information in the case is not determined by the amount of time needed to arrive at these decisions, but the amount of knowledge and experience needed to arrive at the right decision. Time is a factor that is secondary to expertise and experience in the patient’s treatment.
Tying it all together
The chiropractor must use effective tools to determine the objective information necessary to arrive at an accurate diagnosis and treatment plan in today’s practice. Although valuable, an X-ray machine is not always affordable. Therefore, the chiropractor must consider methods to gather objective information in the examination, cause no harm to the patient, and be convenient and affordable.
We can send the patient out to an imaging center. Still, tools such as the 3-D kiosk scan may not only yield specific objective information, but the software will also aid in the determination of the complexity of the scenario and the ideal treatment options.
At no other time have the elements needed to provide improved care for our patients been more accessible. The 2021 E/M guidelines offer a route to guide us in the determination of objective examination findings, the application of the evidence to arrive at a specific diagnosis, and the opportunity to quantify our findings to explain the complexity of the condition and to communicate the specific conditions involved affecting the treatment of our patients. Chiropractors should use all the tools available and embrace the new guidelines more fully.
MARIO FUCINARI, DC, CPCO, CPPM, CIC, is a certified professional compliance officer, certified physician practice manager, certified insurance consultant, and a Medicare Carrier Advisory Committee member. As a member of Foot Levelers Speakers Bureau, he shares his expertise with audiences throughout the country. He can be contacted for classes such as Medicare, documentation, coding, examination or rehabilitation training. For further information, email him at Doc@askmario.com or check his website at askmario.com.