How to Properly Document Medical Decision Making (MDM)

patients electronic accessMedical Decision Making (MDM) documentation is as significant as the other two components of documentation (History and Exam) in assigning an evaluation and management (E/M) service level. The end result of MDM is complexity level or severity of presenting complaint. MDM indicates the intensity of the cognitive labor carried out by the physician. The very purpose of MDM is to make you aware of how you got from the presenting complaint through the evaluation and management to the disposition of the patient. With well-documented MDM, you can increase your reimbursement and stay safe from inevitable audits. Let’s consider how you can document MDM properly.

Specify the Problem with the Plan

As auditors may not have the ability to infer the severity of a case without proper documentation, it is very important to formulate a complete and accurate description of the patient’s condition with equivalent plan of care for each encounter. Specifying problems without the corresponding plan of care does not support physician management of those problems and could result in relegating complexity. Listing problems with brief, generalized comments can also diminish the complexity and efforts taken by the physician. You should clearly document the care plan. The care plan should specify the problems that are personally managed by the physician, along with those that must be considered while formulating management options, even if another physician is primarily managing the problem. Both the quality and quantity of problems should be addressed. Physician documentation should:

• Identify all problems that are managed or addressed at the time of each encounter
• Identify the problem as stable or progressing, when appropriate
• Indicate differential diagnose if the problem remains undefined
• Indicate the management/treatment option(s) for each problem
• Note management options to be continued somewhere in the progress note for that encounter when the documentation indicates a continuation of current management options.

Give Focus to Relevant Data

Data actually comprises pathology/laboratory testing, radiology and medicine-based diagnostic testing that contributes to diagnosing or managing patient problems. Though pertinent orders or results may appear in the medical records, most of the background interactions and communications involved with testing are missed out while reviewing the progressive note. In order to receive credit, you should:

• Specify the tests ordered and rationale in your progress note or make an entry that indicates another auditor-accessible location for ordered tests and studies.
• Clearly document test review along with a brief entry in the progress note. Credit is not given for entries that are short of a comment on the findings..
• Summarize key points when reviewing old records or obtaining history from someone other than the patient.
• Specify that images, tracings or specimens have been ‘personally reviewed.’ Otherwise the auditor will assume that you only reviewed the written report. Include a comment on the findings.
• Summarize any discussions of unexpected or contradictory test results with the physician performing the diagnostic study or procedure.

Don’t Undervalue Patient’s Complexity

A general lack of understanding of the MDM component of documentation may lead to physicians undervaluing their services. Physicians may consider a case to be of ‘low complexity’ simply due to the frequency with which they encounter the case type. Therefore, it is very important to better identify the risk involved for the patient. Patient risk is categorized as minimal, low, moderate or high based on pre-assigned items related to the presenting problem, diagnostic procedures ordered and management options selected.
Chronic conditions involving exacerbations and invasive procedures involve more patient risk compared to acute, uncomplicated illnesses or noninvasive procedures. Stable or improving problems are perceived as ‘less risky’ compared to progressing problems. Conditions that pose a threat to life/bodily function outweigh undiagnosed problems where it is difficult to determine the patient’s prognosis. Medication risk for a particular drug remains the same whether the dosage is increased, decreased or continued without any change. Physicians should:

• Provide the status of all problems in the plan of care and indicate them as stable, worsening or progressing (mild or severe) when appropriate
• Document all diagnostic or therapeutic procedures considered
• Indicate surgical risk factors involving co-morbid conditions that place patients at greater risk compared to the average patient, when appropriate
• Correlate the lab tests ordered to monitor for toxicity with medication to the corresponding medication

Accurately Indicate Complexity Level

MDM is rooted in the complexity of the patient’s problem addressed during a given encounter. Complexity is categorized into straightforward, low, moderate and high. It directly correlates to the content of physician documentation. The auditors only consider the plan of care for a given service date while reviewing MDM. To be more specific, auditors review three areas – the number of diagnoses and/or treatment options, the amount and/or complexity of data ordered/reviewed and the risk of complications/morbidity/mortality. So, it is very important to specify the complexity level correctly.