Critical Elements in Determining Medical Necessity by Properly Communicating Complex Conditions
As we all know, not all cases that come to our office are the same. Some cases have fewer complicating factors and involve multiple regions than others. We shouldn’t document and code every case the same way for the same reason. Changes to Assessment 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 effective January 1, 2021. Previously, the Centers for Medicare and Medicaid Services guidelines for 1995 and 1997 were sometimes not applicable to the chiropractic profession and were often confusing .
In the 2021 E/M guidelines, providers have the choice of medical decision making (MDM) or time as the primary element. We are no longer responsible for documenting unnecessary details to meet E/M requirements. Now, the provider has the choice to review and document medically necessary information to make a diagnosis, assess the status of a condition, and select the appropriate treatment option.
Similarly, the International Classification of Diseases (ICD) has become even more precise since the publication of the ICD-10 coding system in 2015. With more than 72,000 as of October 1, 2021, the ability for the provider to specifically communicate the diagnosis to a third has become easier and more accessible. The complexity of a case assessment and management must be compatible with the specificity and complexity of the diagnosis. The days of neck and low back pain diagnoses are long gone. Indeed, the diagnosis of low back pain (M54.5) has been removed as of October 1, 2021 and has been replaced by more specific diagnoses.
Assessment and management
E/M time-based coding includes face-to-face and remote services as long as they are performed on the day of the encounter. Time-based coding can put the experienced provider at a disadvantage because an experienced provider can complete the same amount of work in less time than a less experienced provider. In this case, the qualified provider should not be punished simply for being more effective in communicating complex conditions.
Therefore, in many cases, medical decision making would be chosen as the method to determine the correct choice of E/M CPT code.
When choosing MDM guidelines for E/M CPT code, a vendor should consider three categories to determine the level of complexity:
- Diagnoses, conditions or problems treated or considered (addressed) regarding the main complaints.
- The amount and complexity of data ordered, reviewed and analyzed on the day of the meeting.
- Risk, comorbidity, or complication factors that should be considered when ordering tests or making treatment options.
For example, suppose a patient has low back pain, associated leg pain, and plantar fasciitis caused by hyperpronation of the feet, causing an abnormal gait. In this case, this represents several factors that must be considered 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 treatment of the patient. Current patients may also have pre-existing conditions such as recent COVID infection causing fatigue, joint pain, muscle weakness and loss of balance.
Complex conditions, x-rays and foot scans
Additionally, if the provider conducts a review and decides that x-rays should be taken due to the current condition, the ordering and x-ray analysis or report would be considered in the complexity of the data to be reviewed and analyze. Since plantar fasciitis and balance changes alter gait, the use of a 3D kiosk foot scanner would be ordered and analyzed to determine the objective cause of plantar fasciitis and treatment options such as molded orthoses tailored.
Additionally, the ordering and prescription of the appropriate custom orthotics would also be documented in medical decision-making. Thus, a foot scan is indicated and gives important objective information to determine the cause of the problem and the ideal treatment. As one can imagine, this scenario is common in the chiropractic office, but rarely documented.
The risk of causing death or complicating conditions when ordering tests or treating the patient in a chiropractic office is extremely low. Therefore, considering the three categories of data, the lowest common denominator of the complexity of two data items is used to determine the E/M complexity level.
Once all the data is documented, analyzed and decided, the nature of the mechanism of injury, treatment options and diagnoses are documented. If all of these factors are reasonably related in terms of complexity and justification, the care is considered medically necessary. When one factor is unrelated 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 determining medical necessity. A basic rule of diagnostic coding is to code what you know to the highest degree of specificity. If there is a complicating factor, this should also be coded and placed last in your list of diagnoses.
For example, if the patient has back pain and sciatica due to impaired gait due to plantar fasciitis, you would diagnose sciatica (M54.41, M54.42) and plantar fasciitis (M72.2). Although impaired gait is present, you would not necessarily code impaired gait, as some may consider gait to be a symptom of the other conditions.
The MDM level exists to identify complexity in establishing diagnoses and assisting in treatment planning. Determining the possible causes and, accordingly, how to proceed with the treatment, the doctor treats the symptoms of the disease and the cause of the disorder.
The order, analysis, and application of information in the case are determined not by the time required to arrive at those decisions, but by the amount of knowledge and experience required to arrive at the law decision. Time is a secondary factor compared to expertise and experience in caring for the patient.
Tie it all together
The chiropractor must use effective tools to determine the objective information needed to arrive at an accurate diagnosis and treatment plan in current practice. Although valuable, an x-ray machine is not always affordable. Therefore, the chiropractor should consider methods to gather objective information during the examination, do no harm to the patient, and be practical and affordable.
We can send the patient to an imaging center. Yet tools such as 3D kiosk analysis can not only provide specific objective information, but the software will also help determine scenario complexity and ideal treatment options.
At no other time have the elements needed to deliver better care to our patients been so readily available. The 2021 E/M Guidelines provide a pathway to guide us in determining objective examination findings, applying evidence to arrive at a specific diagnosis, and being able to quantify our findings to explain the complexity of the condition and communicate the specific conditions involved affecting the treatment of our patients. Chiropractors should use all available tools and more fully embrace the new guidelines.
MARIO FUCINARI, DC, CPCO, CPPM, CIC, is a Certified Professional Compliance Officer, Certified Medical Practice Director, Certified Insurance Consultant, and Medicare Carrier Advisory Board Member. As a member of the Foot Levelers Speakers Bureau, he shares his expertise with audiences across the country. He can be contacted for courses such as health insurance, documentation, coding, review or rehab training. For more information, email him at [email protected] or check out his website at askmario.com.