Body Areas
- Head, including the face
- Neck
- Chest, including breasts
- Abdomen
- Genitalia, groin, buttocks
- Back
- Each extremity Organ Systems
- Eyes
- Neuralgic
- Ears, nose, mouth and throat
- Psychiatric
- Cardiovascular
- Skin
- Gastrointestinal
- Genitourinary
- Musculoskeletal
- Hematologic, lymphatic, and immunologic
The 1997 guidelines include itemized exams for the following for a general or multisystem exam:
- Constitutional
- Eyes
- Ear, nose, mouth, and throat
- Neck
- Respiratory
- Cardiovascular
- Chest (breast)
- Gastrointestinal
- Genitourinary (male)
- Genitourinary (female)
- Lymphatic
- Musculoskeletal
- Skin
- Neurologic
- Psychiatric
Medical Decision Making
The medical decision making (MDM) element is usually the driving force of the visit. This means that the medical decision making must support the medical necessity of the level of the visit. The MDM is comprised of three components: number of diagnoses or treatment options, amount and/or complexity of data to be reviewed, and risk of complication and/or morbidity or mortality.
To reach a level for the MDM, only two of the three components are needed. The lowest component can be disregarded, and the two remaining components should be used to determine the level. The levels of MDM are:
- Straightforward;
- Low complexity;
- Moderate complexity; and
- High complexity.
Once all the levels of each section have been determined, then the decision can be made as to the actual level of visit that should be billed. There are five levels for outpatient visits and three levels for inpatient visits.
Everyone in the practice should be familiar with the coding and billing guidelines of patient visits to guarantee that the correct level of visit will be reimbursed. In the end, if everything is not documented, the level of the visit will not support the medical necessity for the services performed.
This information is just the tip of the iceberg and should be reviewed routinely to verify that there is no fraud or abuse. For additional information on coding and billing, contact Melesia Tillman at [email protected] or (404) 633-3777, ext. 820.
Melesia Tillman is the coding specialist at the ACR.
