Wiki Downcoding due to Medical Necessity?


Mendota Heights, MN
Best answers
What do you do in the instance where the documentation clearly supports, say a 99214, but the presenting problem (say a sore throat) doesn't? Is it legal to code a 99213 even though that wasn't what was documented?
I have seen this as an issue especially with EMR use. Remember the MDM should drive the code. I have downcoded a provider for medical necessity to avoid the appearance of abuse.

Laura Cain, RN, CPC
Agree with gkarow. MDM is the driving force for the E/M level. It's great you have a provider that is such a good documentor (not sure thats even a word, lol). I have some that make it tough to even get a level.
Presenting problem vs diagnosis

The problem I have with this is that the "presenting problem" or chief complaint, is NOT the diagnosis. It's what the patient says is wrong.

I may say I have a sore throat, but only the physician's exam and expertise will diagnosis this as tonsilitis or strep throat or thrush or "just a cold."

I do not downcode based on the presenting problem. I will downcode if the MDM doesn't meet the level of service that the exam & history show.

It's a subtle but important difference.

Hope that helps.

F Tessa Bartels, CPC, CEMC