Auditing of Office or Other Outpatients Services - Level 3 or 4 ?

When the rules for Office and Other Outpatient services changed in 2021, we all adjusted to the Elements of Medical Decision-Making grid as the guide for determining the level of service.  When Hospital Inpatient and Outpatient services changed in 2023, there were some minor adjustments but, honestly, providers were still learning the rules from the 2021 changes.

When looking at the practical aspects of office and other outpatient coding, it seems to come down to is the service one of low or moderate complexity.  A level 3 or level 4.  Visits are frequently incorrectly coded as providers, and sometimes auditors, do not fully understand the nuances of the three columns from the grid and the concepts contained within. 

• Multiple illnesses do not necessarily advance you to the next higher level in the column
• Acute and Severe can mean different levels if properly documented
• A test that is ordered usually gets credit in the middle column while a test interpreted usually does not
• The decision for surgery in the last column does not include referral to a surgeon
• Refill meds is not enough documentation to get credit for medication management

These are a few of the misunderstanding and misnomers that exist about the table.  As an auditor you must understand what is needed.  Providers must understand this as well so they can be sure their documentation will pass on audit.

Webinar Objectives

Understanding what is needed in the documentation to support the requirements of each of the three columns in the table of elements of medical decision making is a must for auditors.  Going through each column and the appropriate documentation will help auditors to see when things are missing but also to help them discuss with their providers when presenting  audit results.

Many providers feel prescription drug management is indicative of a level four office visit.  It might be but the documentation must support the management and satisfactorily meeting another columns requirement.  Simple ways of recognizing compliant documentation of a level four office visit will help one explain to providers what is missing.

Whenever auditing, and then educating providers, a thorough understanding of the requirements is needed to fully explain to the provider why their documentation is deficient and what would be needed to meet the higher level of service.

Webinar Highlights

• Documentation differences for each column in the Elements of Medical Decision-Making Grid between a level three and level four office visit
• How a simple word or two can make the difference between levels of low and moderate in columns of the MDM grid
• Why a high level of medical decision making is hard to achieve
• How diagnoses can help achieve a higher level of MDM
• A simple explanation of Social Determinants of Health and how they can increase the level of medical decision making.  What documentation is needed for them?
• Time – where does time come into play with level three and level four office visits?

Who Should Attend

Coders, Billers, Office Managers, Office Administrators, Nurse Practitioners, Physician Assistants, Physicians