Diabetes patients can present podiatrists with some of their most complex cases and if you don’t evaluate the level of medical decision-making your podiatrist performs for such patients, you can be at risk of undercoding the services—and losing out on money.
Although diabetes patients are regular fixtures in podiatry practices, many podiatry coders inappropriately code the correct E/M level for these visits because they don’t properly evaluate the level of medical decision-making these more medically complex patients require.
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The problem: Assessing the history and exam components of an E/M is fairly straightforward, but medical decision-making (MDM) is complex—requiring you to asses three separate categories:
- number of diagnoses/management options (minimal, limited, multiple, extensive)
- amount and complexity of data (minimal, limited, moderate, extensive)
- level of risk (minimal, low, moderate, high).
To determine the level of risk, you must also assess three subcategories:
- presenting problem
- diagnostic procedures ordered
- management options.
Many podiatry coders slip up on MDM and downcode their claims resultantly.
The solution: Follow these steps to properly assess a visit’s level of MDM and ensure your DPM’s E/M code levels are appropriate.
To determine the level of MDM, you should assign points to each of the three MDM components that your podiatrist performs. The number of points in each category determines the final MDM level. You must have two out of the three MDM components score at a particular level in order to assign that level of MDM. For example, if...
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