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High level evaluation and management

G

Griffin

Contributor
Messages
11
Location
Branford, CT
My question is if the provider is billing a 99214, but the documentation supports a comprehensive history and examination and moderate decision making would it be appropriate to up code the level of service to a 99215 or would the medical decision making drive the level of evaluation and management service?:o
 
You will probably get a lot of other opinions on this issue, however I will tell you that for an established patient you only need to meet 2 of the 3 components to qualify for that level - the guidelines do not specify that one of those components must be the MDM. Therefore, yes you can code a 99215 based on just the History and the Exam. There are times when this is approriate. However, if your provider is consistently doing higher level exams for lower MDMs, I would suggest that you make sure that he is documentating appropriatley to the medical necessity and not to purposely upcode.

I know others may try and dispute this based on the statement that the MDM is the over-arching decision for a level, yada yada - but I offer this information based on what we were advised by our Medicare carrier, Highmark Medicare Services. We have also had come charts reviewed for CERT that were billed as 99214 and they were actually corrected to 99215 using this criteria and we were paid the additional fees!!

Hope this helps you in some way!

Thanks,
 
May be Insurance driven

Hi all,
I don't know if this affects all Anthems, but Anthem Maine now requires MDM as 1 of the 2 for established visits as of 02/01/11. Not sure if others may follow...
 
I agree with Jodi with one small clarification. It is not the MDM that is the overarching criterion it is the medical necessity. Per Medicare's Internet Only Manual 100-04, chapter 12, section 30.6.1 (A), "Medical necessity of a service is the overarching criterion for payment in addition to the individual requirements of a CPT code."

Maryann Palmeter, CPC, CENTC
 
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