Wiki 99231 of 99232 when MDM is low

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wynonna

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I have an inpatient hospital stay for a subsequent visit.
So I have an expanded problem-focused history. AND
expanded problem-focused exam.
BUT medical decision making for this subsequent visit is LOW.
Am I billing 99231 or n 99232?
thank you my fellow coders
 
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99231-99233 require 2 of 3 key components (hx, exam, MDM) to meet or exceed requirements for that level of service.

EPF history gives you 99232
EPF exam gives you 99232
MDM gives you 99231

Looks like a 99232 to me.
 
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Coding guidelines simply require 2 of 3 from history, exam and MDM. Many companies (mine included) have internal policies that MDM must be 1 of 2. By coding guidelines, 99232. If your employer's policy is that MDM must be considered, then 99231.
 
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csperoni said:
Coding guidelines simply require 2 of 3 from history, exam and MDM. Many companies (mine included) have internal policies that MDM must be 1 of 2. By coding guidelines, 99232. If your employer's policy is that MDM must be considered, then 99231.
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Hi Csperoni - Thank you for mentioning the issue with the MDM portion. I too have worked for organizations that mandate MDM has to be 1 of the 2 elements when leveling. Do you or does anyone know if this is a CMS requirement, too (I've looked but can't find anything on the web, until this post)? I'm now coding with an organization that doesn't mandate it, but I've been coding like that for so long (including the MDM in 1 of 2), that it almost seems incorrect to level a inpt sub visit with just the hx & exam. Anyone else coming across the same issue?
 
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trkrgal73 said:
Hi Csperoni - Thank you for mentioning the issue with the MDM portion. I too have worked for organizations that mandate MDM has to be 1 of the 2 elements when leveling. Do you or does anyone know if this is a CMS requirement, too (I've looked but can't find anything on the web, until this post)? I'm now coding with an organization that doesn't mandate it, but I've been coding like that for so long (including the MDM in 1 of 2), that it almost seems incorrect to level a inpt sub visit with just the hx & exam. Anyone else coming across the same issue?
Click to expand...
For subsequent inpatient visits, the coding guidelines are simply 2 of 3 from history, exam & MDM. While I am not aware of CMS directly having a requirement that MDM must be 1 of the 2, I have heard of MACs with that guideline. The theory is to keep coding in line with the overarching medical necessity criteria. You could have a patient who got a paper cut a week ago, no infection or issue and a doc who overdocuments and wind up with a high level visit using hx and exam only. While it's not really a coder's place to question a clinician's actions (in absence of a blatant concern), requiring MDM sort of takes care of that issue.
If I was coding somewhere that MDM was not required, I would code on whatever 2 of the 3 gave me the highest level unless it was something as black and white as my paper cut example.
 
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