In this ED Charting and Coding Series, we have covered Introduction to ED Charting and Coding (PV Card); the History of Present Illness & Past Medical, Family, Social History; the Review of Systems; and the Physical Exam. At last we arrive at the crux of the chart: Medical Decision Making (MDM). In this final section, you show your work and your thought process.
CMS Assessment of Medical Decision Making
The Centers for Medicare & Medicaid Services (CMS) evaluates MDM based upon the highest 2 of the following 3 elements:
The number of diagnostic and management options to be considered
The complexity of data analyzed, including charts, tests, and other sources (family, EMS)
The risk of complications, morbidity, and mortality associated with the presenting problem(s) and subsequently with the procedures and management options for them.
These elements are presented qualitatively in the following table. See each section below for more quantitative scoring systems.
Let’s work through a sample case, and discuss how each section is documented and then scored.
Diagnostic and Management Options
Begin your MDM section with a summary statement of the patient encounter and list your differential diagnosis:
Ms. Example is a 25-year-old woman with a history of prior ectopic pregnancy who presents with acute RLQ pain concerning for ectopic pregnancy, PID, ovarian torsion, appendicitis, or other acute ovarian or abdominal pathology.
This case involves a new, acute problem with a broad differential including several high-risk diagnoses. These will apply to both the number and nature of problems and later to evaluation of risk.
Scoring the number of diagnostic and treatment options is accomplished in most places using the “Marshfield Clinic Scoring Tool,” which is not officially part of the E/M guidelines nor endorsed by CMS or the AMA. The tool tries to infer complexity from the nature of the problem and the effort it will take to address it. The following tables show the tool and the most common conversion from Marshfield “problem points” to the E/M guidelines element for number of diagnostic and management options.
The tool was developed for clinic appointments, but the American College of Emergency Physicians (ACEP) has recommendations to adapt it to the emergency department (ED) setting. The first distinction is new vs established problems. In the ED, most patients present with problems that are new to the examiner, so unless you are caring for a patient on a planned return visit, your cases will either be minor, self-limited problems (1 point for each problem) or new medical problems that require consideration, guidance for care, and often some kind of workup (3 or 4 points for each problem). Contrasted to the clinic setting, where testing is typically done between visits, in the ED we order, perform, and interpret most of our tests during the visit. So any new problem you can diagnose and manage by history and physical exam alone will score 3 points, and those requiring testing to guide diagnosis and management will score 4 points, as in the case of Ms. Example.
Ms. Example’s case should score 4 points for Extensive diagnostic and management options, because of her new abdominal pain requiring further imaging.
The body of your MDM will describe how you work through your differential. Decisions based upon your history and exam require minimal additional information, but cases that require chart review, tests, and images are credited for increasing complexity.
To score your data review, you may use a table to calculate “data points” for the different kinds of testing, interpretation, and record review. In the table below, note that different kinds of testing score separately, and if you are providing your own read (even if you have a radiologist, cardiologist, or pathologist also on record) you get credit for that work. It’s important to include your interpretation of test results, both as part of your thought process and because your input counts.
As a side note, ECG interpretation must include ≥3 of 6 elements:
Comparison to prior
Summary of the patient’s clinical condition
You may also interpret the telemetry monitor recordings, which should include a mention of rate and rhythm.
I have ordered a CBC, BMP, and urinalysis with urine HCG. I will add a serum HCG if this is positive, in which case we will follow with US, or if negative I plan to proceed to CT scan of the abdomen. I also reviewed Ms. Example’s visit with Dr. Gyn 6 weeks ago, which showed that Ms. Example had negative UPT, gonorrhea, and chlamydia testing as well as a benign examination and unremarkable wet prep at that visit.
We will treat Ms. Example’s pain with IV morphine, and nausea with ondansetron.
On reevaluation, Ms. Example’s pain and nausea are significantly improved and she is resting comfortably, but she continues to have RLQ rebound tenderness. I have reviewed her laboratory results, which show an elevated WBC, normal hematocrit, and platelets. Her electrolytes and renal function are all normal. Her urinalysis shows no sign of infection, and urine HCG is negative, making ectopic unlikely. I have ordered a CT scan of the abdomen after discussing the above results with the patient.
I have reviewed the CT scan, which demonstrates a distended appendix with surrounding fat stranding that are concerning for appendicitis without perforation. I discussed with the radiologist the appearance of the right ovary and uterine tube, which are normal. I then consulted Dr. Jen Surgeon, who will admit the patient, and requested IV cefoxitin preoperatively. Ms. Example was informed of the CT scan results and consultation, and is amenable to the plan for admission and likely appendectomy. She will be kept NPO.
This gives us 1 for lab tests, 1 for radiology, 2 for your personal review of the CT scan, and 2 for your review and summation of old records (the OB visit), for a total of 6 data points. This indicates an extensive amount and complexity of data reviewed.
We can also address the level of risk involved for the presenting problem, testing, and treatment plan. The following table gives examples for risk, based upon the categories of presenting problems, testing required, and treatment plans. Important to note: the highest single item in any category determines the level of risk (CMS Evaluation and Management Services Guide, PDF).
The differential diagnosis for RLQ pain in a 25-year-old woman includes causes at each level of risk, and you should tailor both your differential and your workup appropriately to the presenting problem. Failure to account for higher-risk diagnoses, perform adequate testing, and appropriately escalate care are major areas of potential liability for EM providers. For Ms. Example, if you limited your workup to cystitis and ovarian cysts, this would be minimal to low risk. Considering pelvic inflammatory disease (PID) or other serious infection is moderate risk. Being appropriately concerned for appendicitis, peritonitis, and ovarian torsion reaches high risk. Non-invasive testing (labs and radiology) is considered low risk, but use of IV opioids to treat pain places the management level at high risk (drug therapy requiring monitoring).
Our sample case demonstrates High Complexity MDM based upon extensive diagnostic and management options, extensive data review and analysis, and high risk. It was quite thoroughly documented, but the scoring could be accounted for with just two items: a new problem requiring testing and pain treated with IV narcotics.
Work Smarter, Not Harder: Show Your Effort
The MDM is arguably the most important section of the patient’s record. There are many styles of documentation depending on your system, our example reflects the style we have adopted since using computer dictation, and many will be much shorter. Regardless, every MDM should include 3 core elements:
Explain the complexity of the diagnostic and management options available to you by giving a brief summary of your patient’s presentation followed by your differential diagnosis, no matter how short.
Describe and interpret the data that you obtained and reviewed. Be sure to use a phrase such as, “on my interpretation,” when you independently interpret radiographs or ECGs and briefly summarize prior visits that you reviewed.
Be sure to mention the risk the patient is at due to their underlying pathology, the testing that is required to make a diagnosis, and the treatments that you administer or prescribe.
This example demonstrates the core elements of the MDM up to the point of admission for billing purposes, but leaves out the greater proportion of charts you will write: discharges. Documentation of discharge planning, return precautions, and unplanned discharges including those leaving against medical advice (AMA) and risk-minimizing measures will be covered in a future post.