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TrailBlazer MDM Rules
 

 


The Rules are Different for Providers in CO/NM/OK/TX


Many physicians don't realize that there are several different Medicare carriers who may have different rules for auditing physician documentation.  One of these Medicare carriers (TrailBlazer) has recently adopted a completely new set of rules for auditing the key component of Medical Decision-Making.  Therefore, all of our learning programs are presented in two separate formats, depending upon the geographical location in which you practice. 

THE TrailBlazer MDM rules have changed again. The information below is no longer correct.

To see how the rules have changed, take the updated BASIC COURSE.

How it Works

The points
Similar to the standard MDM points system, the new TrailBlazer MDM scoring system adds up "problem points" and "data points" and then combines this information with risk.  The final level of MDM is calculated by referring to a table (similar to the standard MDM table).  But the way you add upthe points is very different in the new TraiBlazer format.

Problem Points
There is some good news and bad news when it comes to adding up the problem points.  The bad news is that the TrailBlazer rules assign the same value to all problems.  Unlike the standard problem points table, you do not get extra points if the problem is new compared to old or worsening compared to stable.  This rule change does not favor physicians.  But there is some good news.  Unlike the old system, this new apprach to problem points seems to give you credit for dealing with co-morbidities--even if you do not speficially address them in your assessment and plan. 

Number of Diagnoses and/or Management Options
#Dx
#Tx
Dx = Tx
New or established problem; no E/M mentioned and problem is NOT clearly a co-morbid condition
O
O
O
New or established problem; no E/M mentioned and problem IS clearly a co-morbid condition
?
O
New or established problem and E/M is mentioned
X
Y
Total Problem Points
 

So, in the above table the physician would insert a number (X) to add up the total number of problems (new OR old) being directly managed.  In addition you may insert a number in the space marked a "?" to include the number of co-morbid condiditons which may impact the problems you are directly treating.

There is even more good news.  In addition to getting credit for co-morbid conditions, for the first time TrailBlazer seems to be allowing physicians to garner more problem points based on what they actually do to address the clinical problems during the encounter.   These so-called "therapeutic points" are tallied up and inserted into the "Tx" column in the space marked "Y".  You'll notice that there are "0"s already pre-inserted into the "Tx" column along the first two rows of the table.  This is because, by definition, these rows are devoted to co-morbidities which you are not explicitly treating.  (Or else they wouldn't be co-morbidities in the first place.)

The following table shows how you can add up your "therapeutic points." 

Problems/Therapeutic Options Points4
Continue same treatment and/or monitoring 1
Drug management (new Rx or change dose of 1 – 3 existing medication) 1
Complex drug management (change or add MORE than 3 drugs) 2
Open or percutaneous procedure 1
Physical, occupational or speech therapy 1
Closed treatment for fracture/dislocation 1
IV fluids 1
Insulin prescription (sc or combo sc/iv), hyperal, or other complex admixture 2
Conservative therapy: rest, ice, bandages, diet 1
Radiation therapy 1
IM injection or other pain management procedure 1
Patient educated on self or home care topics/techniques 1
Hospital admit 1
Hospital admit, other physician contacted 2
Referral to another physician, consultation 1
Other (specify) 1
                                                                                     Total Therapeutic Points

Before you get too excited about how easy it is to add up these extra points, keep in mind that each category can be used only ONCE.  And don't try to get one point each for changing three drugs.  You get ONE point for changing or starting one to three drugs OR two points for changing or starting MORE than three drugs.

Adding Up All the Problem Points
In order to come up with the final tally for the "problem points" for any encounter.  You would add the points for co-morbidities, plus the points for active problems you are managing plus any "therapeutic points" which may apply. 

For example, consider a patient with diabetic nephropathy and renal insufficiency being seen by a nephrologist.  Let's say the patient also has HTN, which is not controlled as well as anemia and proteinuria all of which you actively managing.  Let's also assume that the patient has underlying CAD, which you are not addressing, but is definitely a co-morbidity.  The problem points would be initally added up as follows:

Number of Diagnoses and/or Management Options #Dx #Tx Dx + Tx
New or established problem; no E/M mentioned and problem is NOT clearly a co-morbid condition 0 0 0
New or established problem; no E/M mentioned and problem IS clearly a co-morbid condition 2 0 2
New or established problem and E/M is mentioned 4 Y
Total Problem Points

You would get ONE point EACH for the co-morbidities of DM (which you are not specifically addressing) and CAD.  Therefore there are two total points scored for underlying co-morbid conditions.  You would get ONE point EACH for the three problems you are actively managing (HTN, proteinuria, anemia and renal insufficiency).

Now let's assume that you adjust the patients ACE inhibitor upward (to treat the HTN and proteinuria) and "continue same therapy: for anemia (namely continue Procrit).  In this case, the "Therapeutic Points" table would look like this:

Problems/Therapeutic Options Points
Continue same treatment and/or monitoring                                                    cg1c.gif 1

Drug management (new Rx or change dose of 1 – 3 existing medication)        cg1c.gif 1
Complex drug management (change or add MORE than 3 drugs) 2
Open or percutaneous procedure 1
Physical, occupational or speech therapy 1
Closed treatment for fracture/dislocation 1
IV fluids 1
Insulin prescription (sc or combo sc/iv), hyperal, or other complex admixture 2
Conservative therapy: rest, ice, bandages, diet 1
Radiation therapy 1
IM injection or other pain management procedure 1
Patient educated on self or home care topics/techniques

1

Hospital admit

1

Hospital admit, other physician contacted

2

Referral to another physician, consultation

1

Other (specify)

1

                                                                                     Total Therapeutic Points

2

You would get one point for "continue same treatment and/or monitoring" of anemia and one point for "drug management" for adjusting the dose of one medication.

Therefore, the total problem points for the above clinical example would look like this:

Number of Diagnoses and/or Management Options

#Dx

#Tx

Dx + Tx

New or established problem; no E/M mentioned and problem is NOT clearly a co-morbid condition

0

0

0

New or established problem; no E/M mentioned and problem IS clearly a co-morbid condition

2

0

2

New or established problem and E/M is mentioned

4

2

6

                                                                                        Total Problem Points

8

 

 

 

 

Summing up:  You would get 2 points for the co-morbidities of DM and CAD plus 4 points for each active problem you are managing (HTN, proteinuria, anemia and renal insufficiency) plus 2 "therapeutic points" (one for "continue same therapy" and one for "drug management") for a grand total of 8 "problem points."

The Data Points
Similar to the standard MDM point system, the new TrailBlazer rules also quantify the data reviewed by the physician.  Unfortunately, there is no getting around the fact that these new rules give physicians less credit than the old MDM rules for performing the same cognitive labor.

Using the TrailBlazer MDM point system, the data points are added up as follows:

Data Reviewed

Points

Review/order clinical lab tests

1

Review/order X-rays

1

Review/order tests in the medicine section (PFTs, echo, EKG)

1

Discuss case with consultant or order consultation or discuss case with other physician managing patient

1

Discuss test results with performing MD

1

Order and/or summarize old records

1

Physiologic monitoring

1

Independent review of image, specimen or tracing

1

A quick glance at the above table reveals a disquieting development: They took away our 2's!

Remember, according to the old MDM data point system, we scored 2 points for EACH for "review and summation of old records" and "independent review of image, specimen or tracing."  All of a sudden, those 2's have been replaced by 1s.  Ouch.

Also, they have elminated the separate categories of "decision to order other records" and "review old records" and combined these two actions into a single 1 point category.

There are two bright spots for the new data points.  They have added a category for "discussing the case with consultant, etc." and also for "physiologic monitoring".  This last, rather cryptic category refers to complex monitoring such as nocturnal pulse oximetry or cardiac monitoring--not for recording a pulse oximetry reading with the vital signs.

Overall, the new data points add up to a net negative for physicians.

Risk
Luckily, the new MDM rules adopted by TrailBlazer did not change the criteria for stratifying risk.  Risk is still determined by referring to the table of risk.

Adding it All Up: How to Calculate Your Cognitive Labor
After calculating the Problem Points and the Data Points and stratifying the level of risk, the overall complexity of MDM using the new TrailBlazer rules  is determined by referring to the yet another table.
MDM Points Table
(Two out of three must be present to qualify for a given level of MDM )

Overall MDM

Problem Points

Data Points

Risk

Straightforward Complexity

 ≤ 2

1

Minimal

Low complexity

 3 - 4

2

Low

Moderate Complexity

 5 - 6

3

Moderate

High Complexity

 7

4

High

 
Notice that the number of problem points required to qualify for any given level of MDM has been ratcheted upwards.   The data point requirements are the same, but remember that the new rules make it more difficult to accumulate individual data points.  The risk is unchanged. 

Conclusion
There is little doubt that the new rules adopted by TrailBlazer will lead to a subtle yet systematic de-valuing of physician cognitive labor.  In addition, the new rules will require much more documentation of the MDM than the old MDM point system.  I give TrailBlazer credit for tackling the issue of co-morbidities and also for including the new "therapeutic points" when calculating the total problem points.  On the other hand, the reduction in data point values seems excessive.  

I will continue to try to clarify these new rules in the future and update this page.  Iin the mean time, if you are a physician who is affected by these rule changes, you may want to consider emailing Trailblazer to voice your concerns.  Comments should be directed to the following email address: policy@trailblazerhealth.com

Good luck to the docs in Delaware, D.C., Texas, Virginia and Maryland.  To download a PDF document with the new MDM rules, click here.

Peter R. Jensen, MD, CPC  

E/M University

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