Focus on E/M services: MDM third element

So far in our E/M blog series, we have covered the first and second element of medical decision making (MDM). Today we will cover changes to the third and final MDM element: Risk.

Currently, the 1995 and 1997 AMA documentation guidelines refer to this section of MDM as “Risk of Significant Complications, Morbidity, and/or Mortality.” For 2021, AMA guidelines have changed this to state “Risk of Complications and/or Morbidity or Mortality of Patient Management.” This section is further defined as being based on “patient management decisions made at the visit, associated with the patient’s problem(s), the diagnostic procedure(s), treatment(s). This includes the possible management options selected and those considered, but not selected, after shared medical decision making with the patient and/or family.”

Going through the new guidelines, we found clarifying definitions that we wanted to share.  Below, we will define risk and morbidity, as well as review the levels of risk.  There are a lot of changes coming down the pike, but the overarching criteria haven’t changed. Risk is, in our opinion, the most important.

MDM Element: Risk of Complications and/or Morbidity or Mortality of Patient Management

Per AMA guidelines, Risk and Morbidity are defined as:

The risk of complications, morbidity, and/or mortality of patient management decisions made at the visit, associated with the patient’s problem(s), the diagnostic procedure(s), treatment(s). This includes the possible management options selected and those considered, but not selected, after shared medical decision making with the patient and/or family. For example, a decision about hospitalization includes consideration of alternative levels of care. Examples may include a psychiatric patient with a sufficient degree of support in the outpatient setting or the decision to not hospitalize a patient with advanced dementia with an acute condition that would generally warrant inpatient care, but for whom the goal is palliative treatment. 

Let’s briefly review what Risk and Morbidity include:

Risk

The E/M guidelines for 2021 define risk as “the probability and/or consequences of an event.”  The level of risk for a patient encounter is impacted by the nature of the injury or illness being treated.  For the purposes of medical decision making, the level of risk is based upon consequences of the problem(s) addressed at the encounter when appropriately treated. Risk also includes medical decision making related to the need to initiate or forego further testing, treatment and/or hospitalization.

Morbidity

Morbidity is defined as “a state of illness or functional impairment that is expected to be of substantial duration during which function is limited, quality of life is impaired, or there is organ damage that may not be transient despite treatment.”

Next let’s take a closer look at the four types of MDM recognized and the risk factors for each:

Straightforward

• Minimal risk from treatment (including no treatment) or testing, minimal risk of limited function, quality of life or organ damage based on the presenting problem (Most would consider this effectively as no risk).

Low

• Low risk (e.g., very low risk of severity problems), minimal consent/discussion, low risk of substantial injury or illness duration, limited function, quality of life impairment, or organ damage based on the presenting problem.

Moderate

• Moderate risk Would typically review with patient/surrogate, obtain consent and monitor, or there are complex social factors in management.
• Patient would be at risk for limited function or impact or impairment to quality of life, or potential organ damage based on the presenting problem. Testing or treatment that may increase patient risk include:
  • Prescription drug management by means of prescribing, continuing, modifying, discontinuing, or adjusting the drug.
  • Decision regarding minor surgery (0-10 day global period) with identified patient or procedure risk factors such as comorbidities or other current injuries or illness that may impact surgical outcomes.
  • Decision for elective major surgery (90-day global period) without identified risk factors such as comorbidities or other illnesses or injuries that may impact surgical outcomes.
  • Diagnosis or treatment significantly limited by social determinants of health

High

• High risk includes the need to discuss higher risk problems that could happen for which physician or other qualified health care professional will watch or monitor.
• Patient would be at high risk for limited function, impaired quality of life, or damage to internal organs based on the presenting problem. Testing or treatment that may increase patient risk include:
  • Intensive long or short-term drug therapy monitoring by a lab, physiologic, or imaging test.
  • Decision for elective major surgery (90-day global period) with identified risk factors such as comorbidities or other illnesses or injuries that may impact surgical outcomes.
  • Emergency major surgery, which is typically not previously scheduled due to the urgent nature.
  • Decision to admit patient to the hospital.
  • Poor patient prognosis that results in a decision to de-escalate care or do not resuscitate (DNR).

Today, we score this section of MDM using the Table of Risk. Beginning in 2021, we will only use a modified version of the Management Options column of the Table of Risk. For MDM to be the driver for code selection, the level of MDM must be met based on the new 2021 MDM table for office or other outpatient E/M services. The new table can be accessed here.

As stated by my colleague Rebecca Caux-Harry in her recent blog, our job will be to continue to review the documentation and categorize the problems addressed during the encounter to start to build the level of care based on medical decision making according to the new guidelines. Please continue to watch for our next blog in the E/M series.

Kelly Long is a clinical development analyst with Solventum.

Karla VonEschen is a coding analyst at Solventum.

Jean Jones is a coding analyst at Solventum.

Learn more about the 2021 E/M changes.