There is an issue my ofice is having with determing levels with established patients. The requirements per CPT guidlines is you only need 2/3 components to meet a level. Now our question is due to EMR's, comprehensive History and PE is very common. Or comprehensive and Detailed history and PE. Now if you add this to a system such as 3M, it gives you level 5 and level 4. regardless of the MDM. I find it hard to not have to bring MDM into consideration, so I wanted other opinions on how others are basing this. Are you using the MDM to bring it down a level? Thank you in advance!
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Wiki est. pt- 2/3 comp
- Thread starter selsal
- Start date
Pam Warren
True Blue
Actually, after several complaints from coders like us, our EMR software company created the default configuration for E&M to make MDM one of the two key components that drives the code. NHIC, which is our Medicare contractor has been very clear about using MDM to determine Level of Service, so we were happy to learn that our software (NextGen) could accommodate us.
Prior to that, we provided extensive physician education to recommend to them that when they selected their E&M level of service, that they take MDM into consideration. It wasn't fool-proof, but neither is any EMR.
Our communication to the physicians suggested to them that they consider medical necessity and the nature of the presenting problem in determining if their excessive mouse-clicking made sense. Detailed and comprehensive HPI and ROS are easy in an EMR....but was the work done, and does it relate to the chief complaint? Getting that message across was difficult, but we tried to explain that they had to use the EMR in the same way they would have documented in the paper world. If they didn't document a full ROS for an upper respiratory infection in the paper world, why would they do so in the EMR? Once they made that connection, it was much easier to direct them to do the 'right' thing.
Then you might want to suggest to your EMR vendor that they configure the E&M calculator to select MDM and one other key component to derive the correct level of service.
Prior to that, we provided extensive physician education to recommend to them that when they selected their E&M level of service, that they take MDM into consideration. It wasn't fool-proof, but neither is any EMR.
Our communication to the physicians suggested to them that they consider medical necessity and the nature of the presenting problem in determining if their excessive mouse-clicking made sense. Detailed and comprehensive HPI and ROS are easy in an EMR....but was the work done, and does it relate to the chief complaint? Getting that message across was difficult, but we tried to explain that they had to use the EMR in the same way they would have documented in the paper world. If they didn't document a full ROS for an upper respiratory infection in the paper world, why would they do so in the EMR? Once they made that connection, it was much easier to direct them to do the 'right' thing.
Then you might want to suggest to your EMR vendor that they configure the E&M calculator to select MDM and one other key component to derive the correct level of service.
