- 2023;23;503-525Compliance and Documentation for Evaluation and Management Services in Interventional Pain Management Practice
Laxmaiah Manchikanti, MD, Mahendra R. Sanapati, MD, Vidyasagar Pampati, MSc, and Joshua A. Hirsch, MD.
Evaluation of new and established patients is an integral part of interventional pain management. Over the last 3 decades, there has been significant confusion over the proper documentation for evaluation and management (E/M) services in general and for interventional pain management in particular. Interventional pain physicians have learned how to evaluate patients presenting with pain on the basis of their specialty training. Although modern training programs are introducing residents and fellows to the intricacies of E/M services and federal regulations, this has not always been the case. Multiple textbooks about pain management, physiatry, and neurology, and numerous journal articles have described the evaluation of pain patients, but they have not been specific to chronic pain patients and may not meet the regulatory perspective.
A multitude of these issues led to the development of guidelines in 1995 and 1997, which were highly complicated and difficult to follow. These also led to significant criticism from clinicians. Consequently, further guidance was developed to be effective January 2021.
The crucial concept in the present system of coding for E/M services is medical decision making, which includes 3 elements since 2021:
1. The number and complexity of problems addressed
2. Amount or complexity of data to be reviewed and analyzed
3. Risk of complications and/or morbidity or mortality of patient management
In order to select a level of E/M service, 2 of the 3 elements of medical decision making (MDM) must be met or exceeded. This is in contrast to prior guidelines wherein for new patients, all 3 elements with history, physical examination and MDM , and for established patients have been met. For ease of appreciation, an algorithmic approach created by the American Medical Association (AMA), and Centers for Medicare and Medicaid Services (CMS) approved a new MDM table outlining all of the appropriate criteria.
This review systematically describes the changes and provides an algorithmic approach for application in interventional pain management practices.
KEY WORDS: Evaluation and management services, new patient, established patient, level of service, CPT coding, medical decision making, complexity of problems