Medical Decision-Making:
What It Is and What It Means to You
by Dr. Ron Short, DC, MCS-P, CPC, CPCO
We hear a lot about medical decision-making (MDM) now that it is one of only two ways to determine the appropriate evaluation and management code level. So I thought it would be a good idea to explain exactly what MDM is and how it relates to us.
A good definition for MDM is: “The process by which a diagnosis or treatment plan is formulated from the available test information.” MDM differentiates doctors from support staff, such as CAs, nurses, and technicians. We determine what is wrong with the patient and how to best take care of the problem.
To look at this in greater detail, let’s bring in our old friend SOAP. Of course, we know that SOAP is the acronym for subjective, objective, assessment, and plan, which outlines how our documentation is laid out.
Subjective data is the information we get from the patient or their caregiver/family member. We gather that information by using written history forms, consulting with the patient, discussing with family members or caregivers, and reviewing outside documentation, such as accident reports or charts from other providers.
Objective data is the information the doctor gets by directly observing the patient. That observation can be in the form of an examination, imaging, lab results, or just watching the patient walk down the hall.
Assessment is the doctor’s opinion about what is wrong with the patient. It contains the diagnoses, but it should be so much more. To quote your high school math teacher, you need to show your work (and I apologize for the trauma that memory brings).
The assessment should note which elements of the subjective and objective data are significant and how they factor into your decision when diagnosing the patient’s condition. It should also note any complicating factors that would extend treatment times. A good assessment should look like the following note:
“The patient presented with low back pain radiating down the right leg to below the knee. The Laseque test was positive on the right at 35 degrees, and the confirmatory Braggard test was also positive on the right. This would indicate a diagnosis of M54.41 Lumbago with Sciatica, right side. Since the patient did not seek treatment for two weeks and reported a pain level of 9 on the numeric pain scale, it indicates that the treatment time for this case could be double what is normally expected. The patient will be seen three times per week for four weeks, then reexamined to determine progress and the need for further care.
Started preparing to see the patient at 8:15 a.m. by preparing initial patient packet and finished at 8:19 a.m., for a total of four minutes. Started reviewing patient’s history at 10:12 a.m. then performed consultation and examination, finishing at 10:34 a.m., for a total of 22 minutes. X-rays were ordered, and patient was told to return this afternoon to review plan of care and start treatment.
Reviewed X-ray and exam results and developed plan of care starting at 12:42 p.m. and finishing at 12:57 p.m., for a total of 15 minutes. Patient returned in the afternoon and reviewed exam results, X-ray results, and plan of care starting at 3:16 p.m. and finishing at 3:30 p.m., for a total of 14 minutes. Total time spent on E/M service was 55 minutes, resulting in code 99204. Treatment was initiated at 3:35 p.m.”
The plan is the roadmap the doctor will follow to care for the patient’s condition. A good treatment plan outlines the frequency and duration of visits, treatment goals, and measures that will be utilized to determine if those goals are met.
If we put SOAP into a formula, it would look like this:
Subjective + Objective = Assessment ⭢ Plan
Now, let’s show where MDM is involved in the process:
Subjective + Objective = MDM occurs = Assessment ⭢MDM occurs ⭢ Plan
You can see that medical decision-making occurs twice in the SOAP process, first in determining the assessment and second in determining the plan.
The subjective and objective elements are for data collection, and the forms and procedures that you use are tools to aid in that data collection. The assessment and plan elements are where you use your skills and expertise as a doctor. You employ your most valuable asset — your professional opinion.
Now, I know what you are thinking. “Gee, Dr. Short, this is all well and good, and I’ve learned a lot about medical decision-making, but how does this affect me?” I’m glad that you asked. It saves me from coming up with a clever segue to the next part of this article.
Most of the time, when doctors respond to requests for records from third-party payers, they send in their history and exam forms along with an X-ray report and a list of diagnoses. In other words, they submit raw data from the subjective and objective portions of their documentation. Doing that forces the reviewer to do the MDM for your case, and they are not qualified to do that. There is no guarantee that they will reach the same conclusions that you did either. After all, they are not chiropractors, and they do not have the training and expertise necessary to look at the raw data and make decisions about the nature of the problem and how to properly treat it.
Your notes should contain a summary of the subjective information reported to you; a summary of the objective information that you observed; your assessment regarding what is significant and what it means; and the plan outlining what you are going to do about it and how you will know when you are done. The history and exam forms are included to support what you stated in your notes. Failure to submit documentation in this manner causes false denials that cost time and money to appeal and overturn.
The other side of this is when third-party payers state that your submitted treatment plan should be ignored, and a different treatment frequency should be approved. They are actually overruling your professional judgment and inserting their own, which is getting very close to practicing medicine without a license.
Developing accurate and complete documentation puts you in a very strong position when it comes to third-party payer reviews and audits. When you state your opinion and show how you arrived at it, then the reviewer can only disagree with your opinion, but only if they have equal or greater credentials than you.
Dr. Ron Short is a 1985 graduate of Palmer College of Chiropractic and is a certified Medical Compliance Specialist, a Certified Professional Coder, A Certified Professional Compliance Officer, a Certified Insurance Consultant and a Certified Peer Review Specialist. He presents seminars and webinars across the country on Medicare, compliance, coding and billing, and documentation. He has written five books and several articles on Medicare, billing, coding, compliance, and documentation. He is available to speak at your group or association meeting or to assist you with reviews, audits, appeals or the development of a compliance program for your office. He can be contacted at [email protected] or at 217-653-5921.
