Medical Decision Making
Complexity of medical decision making (MDM) takes into account the number of clinical problems (number of diagnoses or management options); the amount and complexity of data the clinician reviews; and the risk of complications, morbidity or mortality. The MDM criteria for function-oriented workers’ compensation encounters are largely the same as the CMS criteria, with clarification of the types of problems, management options, data and risk that are relevant to workers’ compensation related care. The following is the CMS table for medical decision making level. This same schema can be used for function-oriented encounters appropriate for WC care, with some minor changes in the definition of the categories that inform. See the subsequent tables below for suggested modifications.
Complexity of Medical Decision Making
Medical Decision Making Criteria
The only difference between the CMS and Function-Oriented Criteria for medical decision making complexity is including work disability as a morbidity outcome. (Note that there is a need for separate coding rules for extensive documentation review or case management activities commonly needed in workers’ compensation – these will be addressed in separate documents, and not included in routine E&M encounter elements.)
Level of Risk
Note that chronic work disability is considered a severe outcome, equivalent to loss of life or limb. Risk is based on highest level in any column, as in CMS system. The proposed alternative table showing level of risk is found here.
For CMS auditing purposes, a point system was developed and piloted by the Marshfield Clinic, to help quantify the nebulous criteria for nature and number of clinical problems (minimal, limited, multiple, extensive). This auditing point system was distributed by CMS to Medicare carriers. The “nature and number of clinical problems” are quantified into Problem Points by referring to the following table. Note that a long-standing problem can still be considered a new problem if it is new to the examiner. Points are added, but the maximum is 4.
For this table, the function-oriented criteria are essentially the same as CMS criteria, but different examples are given for typical WC encounters.
The following table shows the CMS Criteria and Function-Oriented alternative criteria for data points, to score the amount and complexity of the data reviewed. (Note that there is a need for separate coding rules for extensive documentation review or case management activities commonly needed in workers’ compensation – these will be addressed in separate documents, and not included in routine E&M encounter elements.)
There is no difference between the CMS and Function-Oriented criteria for medical decision making. Note 2 out of 3 must be present to qualify for a given level.
Calculating Cognitive Labor
Problem Severity Criteria
Problem severity is one of the separate criteria used in determining the level of care by CMS. There is a lot of overlap with Medical Decision Making criteria. Criteria are the same for CMS and Function-Oriented, except that workers’ compensation (WC) Function-Oriented criteria also consider risk of work disability as a measure of morbidity.