Can you get to 99215 without High MDM?

[E/M Coder]

Need advice from coderland. Doc does a comp HX and comp Exam but MDM is only moderate (4 stable chronic conditions and small Rx changes). Since you only need to meet two of the three, can you get to 99215 without the high MDM and yes, Medicare is the payor. Appreciate your input.

[cjmusser]

You will get different answers on this. The official guidelines do not state that one of the 2 compoents be MDM BUT some organizations and even at least one local Medicare carrier have taken this conservative stance.

The thing to remember is that the medical necessity is the overarching criteria for any E/M service. MDM is usually a good gauge of this.

I think that the nature of presenting problem needs to be taken into consideration. A provider can document a level 5 established on every paitent with hitting all of the elements of history and exam - the question is "was the comprehensive history and exam warrented" based on the nature of presenting problem.

Medicare Claims Processing Manual Chapter 12 section 30.6.1 states

"Medical necessity of a service is the overarching criterion for payment in addition to the individual requirements of a CPT code. It would not be medically necessary or appropriate to bill a higher level of evaluation and management service when a lower level of service is warranted. The volume of documentation should not be the primary influence upon which a specific level of service is billed"

In the scenario you are describing it sounds like there could be an justifiable argument either way. I would check with your local Medicare Carrier to find out thier stance on weight of MDM with established patients. If there is nothing posted on their website you can always query them.

Although this was not a straighforward answer I hope this helps
Christie

[KellyLR]

Originally Posted by qcoder

Need advice from coderland. Doc does a comp HX and comp Exam but MDM is only moderate (4 stable chronic conditions and small Rx changes). Since you only need to meet two of the three, can you get to 99215 without the high MDM and yes, Medicare is the payor. Appreciate your input.

Just use "time" factor. if the doctor can document he/she spent more than 50% of face-to-face in time, then why not? Anybody else out here in coderland know how to get around this. I would be interested in reading their input.
But if you only need two out of three and those are met, why push it?
Best,

[ollielooya]

Originally Posted by KellyLR

Just use "time" factor. if the doctor can document he/she spent more than 50% of face-to-face in time, then why not? Anybody else out here in coderland know how to get around this. I would be interested in reading their input.
But if you only need two out of three and those are met, why push it?
Best,

Kelly, you're talking time based EM assignment here, and wouldn't that ALSO necessitate documentation in the medical record that more than 50% of the time was spent in consultation/coordination of care to meet the requirements?

Hope this thread continues. ---Suzanne E. Byrum, CPC

[wassock]

A local E&M expert here in Florida ( MD and CPC) is all for doing the MDM first, thereby setting the tone for what level of history and exam is needed, rather than the other way round. Why do a comprehensive exam with all its components and a comprehensive history, when all the patient has is a sprained/ strained ankle? Simple reason...I'm sure you all know the answer.

[rthames052006]

Originally Posted by wassock

A local E&M expert here in Florida ( MD and CPC) is all for doing the MDM first, thereby setting the tone for what level of history and exam is needed, rather than the other way round. Why do a comprehensive exam with all its components and a comprehensive history, when all the patient has is a sprained/ strained ankle? Simple reason...I'm sure you all know the answer.

I agree with you, I do believe alot of providers do think this way, there was actually an article written by a physician in Hershey Pa; titled Coding from the bottom up. Dr. Weida. We had him speak at one of our chapter meetings and it makes sense to code "from the bottom up".

[KellyLR]

Originally Posted by ollielooya

Kelly, you're talking time based EM assignment here, and wouldn't that ALSO necessitate documentation in the medical record that more than 50% of the time was spent in consultation/coordination of care to meet the requirements?

Hope this thread continues. ---Suzanne E. Byrum, CPC

Yes, you are right. But I think the original question from the thread start was something about the use of 99215 without the High medical decision making. Usually, the provider has already assessed MDM before the rest comes into play. For est. patient, 2 out of 3 qualifies, or time >50% coordinating and counseling the patient care in face-to-face encounter. If one can qualify the documention meeting 2 out of the 3 requirements, then I wouln't sweat the third unless it would also qualify for prolonged services. Otherwise the 2 qualifying elements can represent the use of 99215. Some of the experience I have seen from provider's documentation has been in the use of 99215, MDM was usually rated as High anyways. One thing I always try to do when I see codes like this is to see if they actually qualify for the lower levels and to get out a 1997DG worksheet and work the record to make sure it qualifies for a level 5 encounter. I look for modifier -26, ordered tests, lab codes, pre- op schedule arrangements that were made with the patient, etc. when I look at how the provider can justify his/her MDM, if it isn't documented, well.....

Best Regards

[Lisa Bledsoe]

Originally Posted by KAM5657

qcoder, during a Highmark Medicare Webinar, I specifically asked the same question, (if you have a comp HPI & Exam, but Moderate MDM, can you code this as a 99215?) The presenters answer was "Yes, you only need 2 out of 3 components).
I know, it doesn't seem right to code a 99215 when a patient comes in with "No compalints", stable chronic conditions, no med changes. Our doctors most likely do code this as a 99214. So, would that be undercoding????

If the patient comes in with "no complaints" and stable chronic conditions with no med changes; wouldn't that really be a physical/annual exam/yearly check up? Seems that way to me...

[KellyLR]

Originally Posted by Lisa Curtis

If the patient comes in with "no complaints" and stable chronic conditions with no med changes; wouldn't that really be a physical/annual exam/yearly check up? Seems that way to me...

I'm not sure how it got to this piont from the initial question but if a person comes in with no new complaints and stable chronic conditions (not worsening) with no med changes, Level 5 and Level 4 is too high for this type of encounter.
Best,