Medical Decision Making And The Marshfield Clinic Scoring Tool FAQ

As of 2021, CPT has a definition and description of Medical Decision Making (MDM) specific to the E/M Office or Other Outpatient E/M codes 99202-99215.  There is a separate definition and description for MDM that applies to all other categories of E/M codes (Hospital Observation, Hospital Inpatient, Consultations, Emergency Department, Nursing Facility, Domiciliary, Rest Home, or Custodial Care, and Home Services)

For the Office or Other Outpatient E/M codes 99202-99215, MDM includes establishing diagnoses, assessing the status of a condition, and/or selecting a management option. Three elements define MDM in the office or other outpatient services codes:

• The number and complexity of problem(s) that are addressed during the encounter.
• The amount and/or complexity of data to be reviewed and analyzed. These data include medical records, tests, and/or other information that must be obtained, ordered, reviewed, and analyzed for the encounter. This includes information obtained from multiple sources or interprofessional communications that are not reported separately and interpretation of tests that are not reported separately. Ordering a test is included in the category of test result(s) and the review of the test result is part of the encounter and not a subsequent encounter. Ordering a test may include those considered but not selected after shared decision making. For example, a patient may request diagnostic imaging that is not necessary for their condition and discussion of the lack of benefit may be required. Alternatively, a test may normally be performed, but due to the risk for a specific patient it is not ordered. These considerations must be documented. Data are divided into three categories:
  • Tests, documents, orders, or independent historian(s). (Each unique test, order, or document is counted to meet a threshold number.)
  • Independent interpretation of tests.
  • Discussion of management or test interpretation with external physician or other qualified health care professional or appropriate source.
• The risk of complications and/or morbidity or mortality of patient management decisions made at the visit, associated with the patient’s problem(s), the diagnostic procedure(s), treatment(s). This includes the possible management options selected and those considered but not selected, after shared MDM with the patient and/or family.

For all other categories of E/M codes (Hospital Observation, Hospital Inpatient, Consultations, Emergency Department, Nursing Facility, Domiciliary, Rest Home, or Custodial Care, and Home Services), MDM refers to the complexity of establishing a diagnosis and/or selecting a management option as measured by:

1. The number of possible diagnoses and/or the number of management options that must be considered.
2. The amount and/or complexity of medical records, diagnostic tests, and/or other information that must be obtained, reviewed, and analyzed.
3. The risk of significant complications, morbidity, and/or mortality, as well as comorbidities, associated with the patient’s presenting problem(s), the diagnostic procedure(s), and/or the possible management options.

The focus of this FAQ going forward will be Medical Decision Making (MDM) as it relates to the Emergency Department E/M codes 99281-99285. For more information about MDM for the Office or Other Outpatient E/M codes, 99202-99215 see the 2021 E/M Guidelines FAQ

Both sets of MDM guidelines identify the following types of MDM:

• Straightforward
• Low Complexity
• Moderate Complexity
• High Complexity

The CMS Evaluation and Management Services Guide and the 1995 E/M Documentation Guidelines reiterate the same MDM elements as CPT but provide more explanation and examples for each of the elements.

CPT does not offer further explanation of the number of possible diagnoses and/or the number of management options that must be considered (DMO) other than the following values:

• Minimal
• Limited
• Multiple
• Extensive

The 1995 E/M Documentation Guidelines (DGs) indicate that DMO is based on the number and types of problems addressed during the encounter, the complexity of establishing a diagnosis and the management decisions that are made by the physician. The DGs also state:

• Generally, decision making with respect to a diagnosed problem is easier than that for an identified but undiagnosed problem.
• The number and type of diagnostic tests employed may be an indicator of the number of possible diagnoses. Problems which are improving or resolving are less complex than those which are worsening or failing to change as expected. 
• The need to seek advice from others is another indicator of complexity of diagnostic or management problems.

CPT does not offer further explanation of the amount and/or complexity of medical records, diagnostic tests, and/or other information that must be obtained, reviewed, and analyzed (Data) other than the following values:

• Minimal or None
• Limited
• Moderate
• Extensive

The 1995 E/M Documentation Guidelines (DGs) say the amount and complexity of data to be reviewed is based on the types of diagnostic testing ordered or reviewed. The DGs also offer:

• A decision to obtain and review old medical records and/or obtain history from sources other than the patient increases the amount and complexity of data to be reviewed.
• Discussion of contradictory or unexpected test results with the physician who performed or interpreted the test is an indication of the complexity of data being reviewed.
• On occasion the physician who ordered a test may personally review the image, tracing or specimen to supplement information from the physician who prepared the test report or interpretation; this is another indication of the complexity of data being reviewed.

CPT does not offer further explanation of the risk of significant complications, morbidity, and/or mortality (risk) other than the following values:

• Minimal
• Low
• Moderate
• High

The 1995 E/M Documentation Guidelines (DGs) indicate that risk is based on the risks associated with the presenting problem(s), the diagnostic procedure(s), and the possible management options. The DGs provide the Table of Risk that may help determine the level of the risk. Regarding the Table of Risk, the DGs state: 

• Because the determination of risk is complex and not readily quantifiable, the table includes common clinical examples rather than absolute measures of risk.
• The assessment of risk of the presenting problem(s) is based on the risk related to the disease process anticipated between the present encounter and the next one.
• The assessment of risk of selecting diagnostic procedures and management options is based on the risk during and immediately following any procedures or treatment.

See the 1995 E/M Documentation Guidelines linked below for the Table of Risk.

Many Medicare Administrative Contractors (MACs), auditors, consultants, and coders use some version of the E/M Documentation Auditors Worksheet that the Marshfield Clinic initially published in 1995. At the time, Marshfield Clinic was a large multi-specialty, primarily office-based practice with 30+ clinics throughout Wisconsin. The CMS E/M Documentation Guidelines were beta-tested at Marshfield Clinic before being released for implementation in 1995. As part of that process, clinic staff helped their regional Medicare carrier develop an audit worksheet that included a scoring system that would help someone not involved in the patient encounter assign a value to the MDM based on documentation in the medical record.

The Marshfield method of scoring MDM has never been officially accepted or endorsed by AMA/CPT or CMS. Unofficially, CMS personnel have recognized the MDM scoring tool’s existence and have indicated that CMS neither encourages nor discourages its use by MACs. Some MACs and other payers have a version of the E/M worksheet posted on their website or publish policies related to their interpretation of how to use the worksheet, but it is not an official CPT or CMS policy.  

The Marshfield Worksheet was developed specifically for services provided in an office setting. Unfortunately, this method of calculating MDM does not always apply well to emergency department coding. Patients present to the ED with a wide variety of injuries and illnesses ranging from minor to life-threatening. There are also a multitude of diagnostic tests, therapeutic interventions, and other management options available during the ED visit not available in most office settings.  

Considering the Marshfield Worksheet is not part of the CPT or CMS coding policies and due to the discrepancies between MDM complexities in the office setting versus the emergency department, many ED physician organizations have elected to adhere to the descriptions and definitions of MDM from the CPT book, the 1995 E/M Documentation Guidelines and the CMS Evaluation and Management Services Guide to establish internal and/or proprietary policies for assigning value to the complexity of the MDM.

Table A from the Marshfield MDM scoring tool uses the type and severity of the presenting problem(s) to gauge and assign a point value to the number of possible diagnoses and/or the number of management options considered.

Once the points are assigned, the total is converted to CPT/CMS values.

• 1 point = Minimal
• 2 point = Limited
• 3 point = Multiple
• 4 or more points = Extensive

This is different from the CPT definition of new patient vs. established patient.  A new problem is new to the examining physician/QHP. When queried on the issue, Bart McCann, MD, former Executive Medical Director of HCFA (now CMS), stated, “The decision making guidelines were designed to give physicians credit for the complexity of their thought processes. Giving a physician more credit for handling a problem he or she is seeing for the first time, even when that problem has been previously identified or diagnosed, is within the spirit of the guidelines.”

Due to the episodic nature of emergency care, ED physicians/QHPs don’t maintain an ongoing relationship with their patients. Therefore most ED patients are considered new problem (to examiner) even though they may present with a chronic or previously diagnosed condition.

Because the MDM scoring tool has never been adopted or endorsed by AMA/CPT or CMS, there is no official coding policy or regulatory guidance that defines “additional workup planned.”  However, with the understanding that the Marshfield E/M Documentation Auditors Worksheet was developed in and for an office-based practice, we can look to standards of practice in that setting to better recognize what may qualify as additional workup.

When a patient presents to their primary physician/QHP with a new problem, the physician/QHP performs a history and physical exam appropriate for the chief complaint. In many cases, this will give the physician/QHP the information needed to determine a diagnosis and appropriate treatment. In more a complex case, the physician/QHP may order diagnostic tests; they may have the patient schedule an appointment with a specialist, they may prescribe a preliminary treatment with orders to return for re-evaluation or a variety of other options to get the information needed to establish a diagnosis and determine the appropriate treatment.

If a diagnostic test is ordered during an office-based E/M service, samples for a lab test may be drawn during the encounter, but in many cases, the physician/QHP will arrange for testing at a lab, or the patient will be sent for x-rays, CT, MRI, etc. at a radiology center or outpatient department at a hospital.  If consultation with a specialist is needed, that appointment will be arranged and scheduled for a later date. In both scenarios, the patient is scheduled for a return office visit to review the test results and/or consultation and discuss treatment options during a second E/M service.  In an office-based practice, the MDM for these encounters would be scored as “additional workup planned.”  

In the emergency department, comprehensive diagnostic testing (lab tests, x-rays, CTs, MRIs, ultrasounds, etc.) is readily available to the patient during the ED encounter. The ED physician/QHP can request and receive a consultation from a specialist while the patient is in the ED. The patient can undergo a preliminary treatment regimen and be re-evaluated during the same encounter.  The fact that this level of diagnostic and therapeutic intervention is provided during a single E/M encounter does not discount the severity or complexity of the “the number of possible diagnoses and/or the number of management options that must be considered.”

In cases where the ED physician/QHP has efficiently assessed the number of possible diagnoses and/or the number of management options using the diagnostic and therapeutic interventions available to them, it seems reasonable to recognize the complexity of this process as “additional workup planned” when assigning value for this component of the MDM.

Again, the MDM scoring is not part of the official coding policy from CPT or CMS, so there isn’t any guidance on determining what qualifies as additional workup planned. The MDM scoring for DMO is trying to establish when minimal, limited, multiple or extensive diagnoses or management options are considered. 

ED physician practices and their coders should determine what type or how many ancillary tests, consultations, etc., accurately indicate when there has been an extensive number of diagnosis or management options considered.  It may not be appropriate to assign an extensive number of diagnosis or management options for a patient that solely received a single simple test, such as a strep test for a sore throat or a single x-ray for an ankle injury. Conversely, when a patient has labs and ultrasound for abdominal pain or an EKG and bloodwork for chest pain, it seems suitable that this level of diagnostic work indicates an extensive number of diagnosis or management options.

Table B from the Marshfield MDM scoring tool assigns points to the different diagnostic tests and other data elements that can be obtained, reviewed, and analyzed during the E/M encounter.

Once the points are assigned, the total is converted to CPT/CMS values.

• 1 point = Minimal or None
• 2 point = Limited
• 3 point = Moderate
• 4 or more points = Extensive

No, as of 2021, the Marshfield scoring's current interpretation is 1 data point assigned per test. Only ordering the test, only reviewing the test, or doing both is only 1 point.

Under the traditional interpretation of the Marshfield scoring, the answer would be no. There has not been a multiplication factor for Table B.  Only one point was assigned for each type of test regardless of how many tests were ordered/reviewed.

With the 2021 modification to the E/M guidelines section of CPT due to the implementation of the new guidelines for office visit codes, the answer may not be as clear-cut as it once was.  CPT 2021 allows the physician/QHP to receive credit for each individual test ordered, as well as credit for each individual test reviewed.  However, this guidance is under the heading for the office visit codes as part of the revised guidelines for determining office or other outpatient E/M codes 99202-99215. Given that some of the office visit codes’ guidelines are duplicated under the “All E/M Services” heading of the E/M chapter of CPT, there may be an argument to be made that points could be counted for each individual test, table B.

Table B recognizes how the need to obtain further information to accurately diagnose and treat the patient increases medical decision-making complexity. Two thought processes receive credit for old records and/or obtaining a history from someone other than the patient.  The first is the decision that additional information is needed.  That decision is scored with 1 point.  The second part of the process is reviewing information obtained and using it in the decision making process. That thought process is scored with 2 points. 

Appropriate documentation is necessary to score the additional 2 points, per the 1995 E/M DGs “Relevant finding from the review of old records, and/or the receipt of additional history from the family, caretaker or other source should be documented. If there is no relevant information beyond that already obtained, that fact should be documented.  A notation of “old records reviewed” or “additional history obtained from family” without elaboration is insufficient.”

CPT defines another healthcare provider as “an external physician or other qualified health care professional who is not in the same group practice or is of a different specialty or subspecialty. This includes licensed professionals who are practicing independently. The individual may also be a facility or organizational provider such as from a hospital, nursing facility, or home health care agency.”

No, only 2 points are counted for any or all of the elements in that row of table B.

The physician/QHP must personally look at the image, tracing or specimen, not simply review the written report from another provider.  The physicians/QHPs visualization should be documented but does not need to meet the standards of a report prepared by a specialist or satisfy the requirements for assigning the CPT code for interpretation.

No, per CPT, “for the purposes of data reviewed and analyzed, pulse oximetry is not a test.”

There are data 3 points that could be assigned to each ECG or X-ray.  One point is assigned for ordering the study and/or reviewing the results. An additional two points can be added when the physician/QHP has documented their independent visualization of the image or tracing. For a total of 3 data points, when the ECG or X-ray is interpreted by the ED physician/QHP.

Historically, the 2 data points for the independent visualization were a way to show the additional mental effort associated with establishing a diagnosis and/or selecting a management option based on the physician’s/QHP's own interpretation of an ECG or x‐ray. The 2 points for the interpretation were not intended to replace the reimbursement for performing and documenting an interpretation.  

In the 2021 MDM grid for the office E/M codes, there is the data element “independent interpretation of a test performed by another physician/other qualified health care professional (not separately reported).” The office E/M guidelines define independent interpretation as “the interpretation of a test for which there is a CPT code, and an interpretation or report is customary. This does not apply when the physician or other qualified health care professional is reporting the service or has previously reported the service for the patient.” The description of the data element and the definition is under the heading “Guidelines for Office or Other Outpatient E/M Services.”

However, edits to the E/M section of CPT have resulted in some of the policy statements and guidelines intended for the office E/M codes to be listed under the heading “Guidelines Common to All E/M Services.” This may impact the coding process for the other E/M code sets, including the ED E/M codes. 

In the description of “Services Reported Separately,” the 2021 CPT states, “the ordering and actual performance and/or interpretation of diagnostic tests/studies during a patient encounter are not included in determining the levels of E/M services when the professional interpretation of those tests/studies is reported separately by the physician or other qualified health care professional reporting the E/M service.” 

However, CPT does not provide or endorse any method for determining the levels of E/M services other than the 2021 Guidelines for Office or Other Outpatient E/M codes. It is unclear how this statement could be applied to the other E/M code sets without an official method for determining the levels of E/M services.

As previously stated, many ED physician organizations have elected to abide by the descriptions and definitions of MDM from the CPT book and the 1995 E/M Documentation Guidelines; others have developed a proprietary process to assign MDM, while others have adopted some version of the Marshfield scoring method. Regardless of which method is used, organizations should review the 2021 CPT guidelines to best incorporate this CPT statement into their process for scoring the MDM for ED E/M codes.

Whether or not this 2021 policy statement is going to be adopted by organizations using Marshfield scoring, some consideration should be given to also incorporating the guidance that data points should be applied for each individual test ordered/reviewed. If the goal of the data scoring is to determine when the amount and/or complexity of medical records, diagnostic tests, and/or other information that must be obtained, reviewed and analyzed has been minimal, limited, moderate, or extensive, a patient that has had a CBC, Chem 7, Troponin, Chest X-ray, a FAST exam and EKG certainly seems extensive regardless of who billed the interpretations. However, limiting the data points because the same provider billed the interpretations could potentially limit the data points to 2 or even 1, which would be considered minimal or limited. That does not seem like an accurate measure of the complexity of medical decision making. Applying data points for each individual test ordered as indicated in CPT 2021 would result in a more suitable measure of data obtained, reviewed, and analyzed and allow for selecting an E/M code that correctly reflects the level of service provided.

The Table of Risk used in the Marshfield method of scoring MDM is the only part of the scoring method pulled directly from the 1995 E/M Documentation Guidelines. The Table of Risk uses the presenting problem(s), the diagnostic procedure(s) ordered, and management options selected to determine if the risk of significant complications, morbidity, and/or mortality is minimal, low, moderate, or high with the highest level of risk in any one category (presenting problem(s), diagnostic procedure(s), or management options) determining the overall risk.

As an example, when a patient presents with an injury, the coder is relying on the documentation to determine if it is an acute uncomplicated injury (low risk), an acute complicated injury (moderate risk) or an injury that poses a threat to life or bodily function (high risk). Clear documentation of the patient’s chief complaint, associated signs and symptoms, differential diagnoses or “possible,” “probable,” or “rule out” diagnoses and final diagnosis will help the coder make the correct determination. Furthermore, diagnostic and therapeutic interventions also contribute to understanding the risk of the presenting problem.

In addition, the 1995 E/M DGs state:

• For each encounter, an assessment, clinical impression, or diagnosis should be documented. It may be explicitly stated or implied in documented decisions regarding management plans and/or further evaluation.
• Comorbidities/underlying diseases or other factors that increase the complexity of medical decision making by increasing the risk of complications, morbidity, and/or mortality should be documented.

The risk for selecting a diagnostic procedure is based on the risk during and immediately following the procedures. For example, on the risk table, x-rays EKG, urinalysis, and ultrasound are in the minimal risk category, meaning there is minimal risk the diagnostic procedure will cause significant complications, morbidity, and/or mortality to the patient. A patient with a presenting problem that requires an EKG or ultrasound will likely be considered high risk in the presenting problem column.

Treatment rendered in the ED, orders given at discharge, procedures ordered, planned, scheduled or performed, medications given in the ED, prescriptions written, follow-up appointments, etc., are all factors in assessing the risk based on management options selected.

The classification of surgery into minor or major is based on the common meaning of such terms used by trained clinicians. These terms are not defined by a surgical package classification.

Elective procedures and emergent procedures describe the timing of a procedure when the timing is related to the patient’s condition. An elective procedure is typically planned in advance (eg, scheduled for weeks later), while an emergent procedure is typically performed immediately or with minimal delay to allow for patient stabilization. Both elective and emergent procedures may be minor or major procedures.

See the 1995 E/M Documentation Guidelines linked below for the Table of Risk.

Additional Resources

1995 E/M Documentation Guidelines:  https://www.cms.gov/outreach-and-education/medicare-learning-network-mln/mlnedwebguide/downloads/95docguidelines.pdf

CMS Evaluation and Management Services Guide 2021: https://www.cms.gov/outreach-and-education/medicare-learning-network-mln/mlnproducts/downloads/eval-mgmt-serv-guide-icn006764.pdf