A New, Three-pronged Approach to the 2021 E/M Guidelines

Our 3-Pronged Approach

Along with the 2021 E/M changes, we auditors need to evolve too. We need to think differently. Rather than reading the note, top to bottom, then looking for words to check off our bullets, we must think more like a clinician and understand who the patient is. By doing so, you’ll be more informed and, therefore, more likely to select the correct level of service. With that philosophy in mind, we developed a new 3-Pronged Approach to better understand the patient’s problem.

Let’s dive in.

1. Understand the Patient

Age. Is the patient a newborn baby, a teenager, or an elderly senior? Age factors into the risk portion of MDM. For example, a teenager with a splinter embedded in their skin is likely easier to treat than a newborn with the same issue.

Reason for Visit. Look beyond just the chief complaint. The HPI tells the full story. Has the splinter been embedded long? If so, there could be a potential risk of infection. Where is the splinter? Some anatomical locations are harder to get to than others or could impact the treatment if nerve damage were likely.

Past History. The Past Family and Social History (PFSH) has a great impact as well. Is the patient on medications like an anticoagulant? That could cause them to bleed more when the splinter is removed. Are there any diseases that could be impacted by this pesky splinter? Let’s say the patient has had a transplant and is on drugs to suppress the immune system. That could cause them to be at greater risk of infection.

Now you can see why the History component is still important to review, even though it no longer counts for office visit levels. Every patient is different and knowing the entire scenario will aid you in selecting your level of risk. Now, let’s move onto the problem.


2. Understand the Problem

Acuity of Problem(s). Just how bad is this, exactly? For some diseases, it's more obvious than others. For example, a cancer patient is at higher risk than our splinter patient. Other diseases aren’t as well known, or they can be chronic, severe, or just a minor issue (think hangnail!). If I don’t know much about a diagnosis, I’ll use my AAPC Codify software or “Dr. Google” to look it up.

Severity. The severity of the problem may not always be stated in words, so you may have to play detective in order to find it. Look at the vital signs:

      • Is their blood pressure up? That can be one of the first signs of a nasty problem.
      • Are they running a fever and if so, how high? Look at any lab results for that date – is there anything that is severely abnormal?
      • If they have a wound, how big is it? The pain scale is also a good source.

Chronic Conditions & Comorbidity. As we mentioned earlier, some diseases can affect the problem, and some may not. Does the physician specifically mention the disease or medications linked, or does he say the disease is controlled? Here, we need to be careful! Just because a problem is mentioned, doesn’t mean it always affects the chief complaint. (HINT: Read your AMA definitions for Problem, Problem Addressed, and Stable Chronic Illness, among others.)

Differential Diagnosis. Although we don’t code problems that are not definitive, we can look at them to determine what direction the provider is going in. Let’s abandon our splinter patient now and look at a patient with a scalp laceration. What differential diagnosis does the provider notate? What about dizziness, frequent falls, or other neurological symptoms? What if there is no definitive diagnosis yet and further work is needed? That would put the patient in more of a moderate risk category than a low risk. This is why you need to think like a clinician. And since you won’t always know much about the problem, you need to look for clues and do research to figure out just how ill the patient really is.

3. Understand the Risks

What are the risks if the patient isn’t treated? What are the risks if they are treated? A UTI of a young, healthy 20-year-old is far different than that of an 89-year-old. Many elderly patients have acute mental status changes with a UTI. Treatment will be much different. What if the patient is diagnosed with cancer, but is against chemotherapy? The provider still recommended it, and as per the new AMA definitions, we can count that towards risk even if the patient declines treatment.

Over-the-Counter (OTC) meds with other chronic meds. Now, keep in mind that it’s hard to play pharmacist. We auditors cannot easily know which medications will react with others. Look for clues in the provider’s documentation, such as: Patient given XXXXXXX once per day and instructed to take separately from their insulin. Or, the patient was given information regarding use of antibiotics with birth control pills.

Risks complicating other problems. One of the most common is the risks involved with surgery. If the provider doesn’t mention anything other than the usual “discussed risk of infection, bleeding, etc. with the patient and they agreed to proceed,” then your patient is at a lower risk than a patient that will need additional testing prior to their procedure (think EKG, specialist pre-op consult). (HINT: Read the AMA’s definition of Risk.)

Social Conditions Impacting Risk. Here we need to review the patient’s social history and any provider notes in the Assessment & Plan (A&P). Is the patient homeless? (Now, let’s go back to our splinter issue.) A homeless patient with a splinter may not have sought care at all unless it was infected. They also won’t likely return for their follow up. And, as we all know, a patient with a current tobacco, alcohol, or drug problem will be at more risk than someone clean and sober. If they are jobless, they may not be able to afford any prescriptions.

As you can see, getting the full story behind the patient’s issues is important to selecting the correct level of service. Educating providers to document clearly is necessary for them to receive the deserved reimbursement for their services. And, as always, it’s our job to stay up-to-date on any changes, to make sure they evolve with our ever-changing times!


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