1. UHC, DMO, and AWP UHC REIMBURSEMENT POLICY
CMS-1500 Evaluation and Management (E/M) Policy Number 2017R5007A
Annual Approval Date 4/21/2017
Approved By UHC Payment Policy Oversight Committee

2. UHC Policy is Proprietary
UHC policy is based on an Optum proprietary Scoring Tool.
UHC Policy also based on HCFA/CMS Evaluation and Management Guidelines.
UHC and Optum Tool adopt Marshfield Clinic Additional Work-up scoring and adds a unique UHC definition of AWP in Emergency Medicine

3. UHC AWP Policy
Additional Work-up Planned is an element of review which includes a number of diagnoses and management options. The Additional Work-up Planned element contributes to indicating the complexity of a patient based on the clinician’s utilization of diagnostic tests.
The Additional Work-Up Planned is a key element for a highly complex E/M service and constitutes any testing/consultation/referral that is being done beyond that Encounter to assist the provider in medical decision making. An example of Additional Work-Up Planned is when the provider of service contacts the patient’s physician or other specialist with recommendations for additional follow-up care and the discussion is documented in the medical records. A simple instruction to the patient to contact their primary physician does not constitute Additional Work-up Planned.

4. Par vs Non-Par
ED Providers are required to participate with Medicare and Medicaid by their facilities. If/when a Medicare or Medicaid contractor invokes an unfair coding or reimbursement policy we must appeal for change. 
Note that there is a difference between coding requirements when the Provider is non-par or non-contracted with a payer that unilaterally incorporates proprietary unique and unfair coding policies?

5. Number of Diagnoses and/or Management Options (DMO)
DMO as stated in the HCFA (CMS) 1995 Documentation Guidelines does not specifically mention “Additional Work-up” Planned (AWP)
DMO as stated in CPT does not mention AWP
AWP is a 1995 Marshfield Clinic Construct.

6. Marshfield Clinic
Marshfield Clinic is a large multi-specialty physician practice that today has 700 Physicians in Wisconsin.
In 2008, Marshfield Clinic obtained its first hospital.

7. Copyrights
Marshfield Clinic developed over 3 versions of their office based coding tool.
Version 3.1 was Copyrighted in the 1990’s and licensed to MGMA. The tool was sold by MGMA in packages of 30.

8. The Marshfield Tool
The Tool was never modified for hospital based use and was never tested by hospital based Providers.
The Tool was never authorized, certified, or recommended by HCFA or CMS for Hospital Based Physicians.

9. DMO According to Hoyle
AWP is not a specified criteria for determining the complexity of the, “Number of Diagnoses and/or Management Options”.
The Number of Diagnoses and/or Management Options considered and/or confirmed = Complexity of DMO.

10. AWP is a Management Option
AWP is not mentioned in DMO in the DGs, however AWP should be considered as a “Management Option”.  
If one equates AWP as one of many possible “Management Options” in DMO then one must conclude that AWP can be scored in the Emergency Department. 
According to the DGs, “Management Options” considered may be performed during or after the time of service.

11. HCFA (CMS) ‘95 Guidelines
The 1995 DG’s indicate: One should use the number of possible diagnosis and/or management options to determine if the complexity of DMO is Minimal, Limited, Multiple or Extensive.

12. The ‘95 DGs Say:
The DMO counted should only include diagnoses, possible diagnoses, and/or management options that are pertinent to the presenting problem or presenting signs or symptoms.
The 1995 DG’s state: The number of possible diagnoses and/or the number of management options that must be considered 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.

13. What Do the DG’s Include?
Clearly the DGs indicate that Differential Diagnoses considered (and documented) are as important as signs, symptoms, and a final Diagnosis when counting the Number of Diagnoses and/or Management Options.

14. What are Management Options
The 1995 DG’s also provide some clarification on what constitutes a management option. Treatment includes a wide range of management options such as: patient instructions, nursing instructions, therapies, and medications.

15. DG’s Also Indicate
Clearly the consideration and/or ordering of diagnostic studies are also Management Options used to establish a Diagnosis and included in when determining complexity of the number of Diagnoses and/or Management Options.

16. Minimal, Ltd, Multiple or Extensive
Using a direct comparison of the 4 levels of DMO then the resulting possible number of Diagnosis and/or management options considered relative to the complexity of DMO is:
• 1 Possible Dx and/or Mgmt Options = 1 point Minimal
• 2 Possible Dx and/or Mgmt Options = 2 points Limited
• 3 Possible Dx and/or Mgmt Options = 3 points Multiple
• >4 Possible Dx and/or Mgmt Options = 4 points Extensive

17. DMO by CPT
CPT Guidelines: The number of possible diagnoses and/or the number of management options that must be considered. The complexity levels of DMO listed in CPT (the Levels of DMO are not individually defined in CPT as these levels are considered basic to physician practice) they are: Minimal, Limited, Multiple, and Extensive.

18. Logic Dictates Minimal = 0 – 1 Limited = 2 Multiple = 3
Extensive = 4 or more

19. Speaker Contact Info.
Mark Owen, President Medical Coding Solutions.
Mobile:
Co-Chair of EDPMA Quality Coding and Documentation Committee
Slides content reflects Speaker’s Opinions