The Rules are Different for Providers in TX/VA/MD/DE and D.C.
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.
If you practice medicine in Texas, Virginia, Maryland, Delaware or the District of Columbia, you should be aware that you have to follow the new Medical Decision-Making rules which are explained below. If you practice anywhere else, you should continue to follow the "regular" Medical Decision-Making rules.
TrailBlazer (the Medicare carrier for these states) has adopted a new set of rules to quantify physician cognitive labor. The new rules make it harder to for physicians to accumulate "problem points" and "data points." In addition, the number of points needed to qualify for any given level of medical decision-making has been adjusted upward.
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  |
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
|
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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