CPMA Study guide Question

coder21

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I am using the 2016 study guide. The question says what level would this be and it states the answer under the rationale that the hpi is expanded focus, the exam is expanded problem focus and the mdm is straightforward. I coded it as a 99212 because of the 2 out of 3 and one should be medical necessity. The study guide says 99213?

Thank you for your time.
 

Chelle-Lynn

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Using the Evaluation and Management Tables:

* For an Established Patient
HPI = Expanded is 99213
Exam = Expanded is 99213
MDM = Straightforward is 99212

So for 2 out of 3 it would be a 99213.
 

coder21

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True but the whole first chapter talks about Medical decision making and medical nessicity and that one of the two should be MDM which is why I said 99212. So when taking the exam do you know go by MDM?
 

pclaybaugh

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True but the whole first chapter talks about Medical decision making and medical nessicity and that one of the two should be MDM which is why I said 99212. So when taking the exam do you know go by MDM?
There are two schools of thought regarding this topic.
One believes it may and should document and calculate E/M levels based on any two of these three components. Following the guidelines in the narrowest sense, choosing any two would claim to justify high levels of E/M service even though one might consistently use only history and exam criteria. The other group states that medical decision making drives medical necessity and must be one of the two components MDM would trump history or exam because medical decision making represents the actual value of a physician’s work. To justify billing for a relatively high level of E/M services one has to find the right balance. I believe that the MDM should drive the process. However using the guidelines, the 99213 would technically be the correct choice.
 

coder21

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Thank you! I go by the MDM drives the level. But I understand per the rule it does make the 99213. I will have to remember to go by the actual CPT rules.
 
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