Wiki Help..Hospital subsequent ? e/m

[lr09050828@gmail.com]

I got my cert last December 2019 and I began doing Hospital inpatient in July. Going over the E/M using the auditor tool knowing 3 out of 3, and 2 out of 3. I felt comfortable going forward after how my manager explained it. But 5 months later she said that the MDM "has" to be on of the two to determined what code.
Here is an example...a subsequent hospital HX-EPF,Exam-Comp and MDM-SF/or Low. She told me two out of three I can post a 99232. But now same situation she said since the MDM is a low it has to be one of the two to be consider 99232. If not than it should be 99231. Is it company specific policy or Medicare policy that the MDM has to be one of the two components. I'm so confused now.

 

[thomas7331]

Requiring that MDM be one of the elements that meets the level needed for code assignment on subsequent/established patient visits is a company-specific policy - Medicare does not require this. It is contrary to CPT guidelines, and in my opinion it is incorrect coding.

However, some organizations elect to follow this policy to prevent up-coding/inflation of E/M levels due to providers' reliance on templated history and exam sections which will often always meet the requirements of a higher level but which may not necessarily be justified by medical necessity. In my experience, though, this practice, when used without discretion, is not a reliable way to correct the problem and may often result in inappropriate down-coding and undervaluing providers' work.

 

[lcolborn]

I got my cert last December 2019 and I began doing Hospital inpatient in July. Going over the E/M using the auditor tool knowing 3 out of 3, and 2 out of 3. I felt comfortable going forward after how my manager explained it. But 5 months later she said that the MDM "has" to be on of the two to determined what code.
Here is an example...a subsequent hospital HX-EPF,Exam-Comp and MDM-SF/or Low. She told me two out of three I can post a 99232. But now same situation she said since the MDM is a low it has to be one of the two to be consider 99232. If not than it should be 99231. Is it company specific policy or Medicare policy that the MDM has to be one of the two components. I'm so confused now.

Most likely it's Company policy. Same with mine, we don't drop the MDM. We always start with the MDM. You might want to clarify it with your company to have a clear understanding .

 

[csperoni]

Third vote for company policy. My company had this same policy for outpatient E/M prior to 2021. I don't agree with it, but I did need to follow their policy (after voicing my dissent).

 

[lr09050828@gmail.com]

Thank you everyone...after speaking w/my manager she did advise me it was company specific too...a lot of 99231 I guess..Thanks again