How to incorporate data in your medical decision-making

I have heard you mention in one of your presentations that you need to make sure you document that you have used data in your medical decision-making (MDM) to count the data as part of MDM. What does this mean?

MDM is intended to measure the relative mental-work effort required to manage a patient complaint. Documentation of the data reviewed/ordered and the reason the information is required not only reflect the mental work needed for a problem but support the medical necessity of the test. Unnecessary tests have been a target of many chart reviews. Poor documentation of the reason and use of these tests has resulted in several large take-backs for a number of urologists over the past few years for both the test payment and a change in the evaluation and management (E/M) code reimbursed.

We have addressed documentation of data as part of MDM because the appropriate use of data as part of MDM was a focus of several payer chart reviews prior to the adoption of the new E/M guidelines. As such, the question is a good one and applicable to both office-visit codes under the new guidelines and the other E/M

codes still under the old guidelines.

To protect your practice from take-backs and support the level of service, we recommend the following:

• For each test/image/diagnostic service ordered, include a clear reason/diagnosis supported by the patient’s presentation for the visit.

• For each test/image/diagnostic service result reviewed, list the relevant information/result in association with a treatment or follow-up next step.

This can be as simple as listing the orders such as Cysto/Cytology/CT for Gross Hematuria standard work-up or can be supported in more detail to include rule-out diagnosis codes in addition to the diagnosis driving the orders.

For results reviewed, it is not enough to simply list results in the medical record. However, you can be concise in referencing the data in conjunction with the next step—for example, postvoid residual 35 mL continue current medication.

In short, good documentation is not necessarily measured in the number or words included in the medical record. However, it does require that the chart note can be followed by other medical professionals for continuity of care. Unfortunately, it should also demonstrate to the chart reviewer, typically not a medical professional, that the information reviewed/ordered was obviously related and required to address the patient’s medical needs.