MDM Tool

What is MDM Tool?

The Center for Medicare and Medicaid Services (CMS), with guidance from the American Medical Association (AMA), implemented a new evaluation and management (E/M) coding system for outpatient visits effective January 1, 2021. This was the first change in 25 years and was developed to ease the documentation burden on medical providers.

Dr. Andrew Schuman and Robert Schuman developed MDMTool.org to assist providers in coding according to the new guidelines. Simply select elements of MDM or time associated with a visit (time component coming soon), click ‘Generate MDM Text,’ and copy the generated text into the bottom of your office note. By doing this, you will indicate to any coder working for an insurance company reviewing your claim that you have made every effort to code appropriately. Dr. Schuman also suggests listing as many appropriate visit diagnoses as one can for every office visit.

---

More about the Updated CMS Guidelines

What's New

The updated CMS guidelines are based on 1) a clearer method of assigning MDM and 2) a new methodology for assigning a time component to the visit on the date of service.

This webinar discusses the new coding system in detail.

The new guidelines:

• Eliminate patient history and physical as elements for code selection
• Give providers the option of choosing whether visit documentation is based on MDM or time associated with the visit on the date of service
• Modify the criteria for MDM by removing ambiguous terms, clearly defining important terms and concepts, and redefining the data MDM measures

In the opinion of Dr. Schuman, the data element component of MDM remains too complicated and rarely elevates an office visits category appropriately, and thus suggests using the more practical ‘code by time’ method.

Coding by MDM

As in the past, CMS recognizes 4 levels of MDM (`straightforward,` `low complexity,` `moderate complexity,` and `high complexity`). MDM quantifies the complexity of establishing a diagnosis and/or selecting management options by measuring:

• The number and complexity of problems addressed at the encounter
• Amount and/or complexity of data to be reviewed and analyzed
• The risk of complications and/or morbidity of patient management

Coding by Time

Indicating the time associated with an encounter is an alternative method of determining the level of the visit. For many, utilizing time to determine a level of service is much less confusing and more straightforward compared to assigning a level of service using MDM. In contrast to the pre-2021 method of assigning time associated with the face-to-face time spent counseling the patient or coordinating care, now time consists of the following elements:

• Time spent preparing to see the patient, reviewing tests and external notes
• Time spent obtaining a history from the parent
• Time spent performing an examination
• Time spent ordering medication or tests
• Time spent referring to, and if necessary, communicating with other health care providers regarding management
• Time spent documenting in the health record
• Time spent communicating results (on the day of service) with the patient/family or caregiver
• Time spent in care coordination

Contact Us

Your comments and suggestions are welcome. Please email info@medgizmos.com.

• Andrew Schuman, MD
• Section Editor, Practice Improvement, Contemporary Pediatrics
• CEO, MedGizmos.com
• https://www.medgizmos.com