Wiki History & Exam outweighing MDM

[tfischer]

For an established patient visit only two of the three components need to be met in order to obtain a level of care. I have a few physicians that are overdocumenting on the established patient encounters. With an end result of the history and examination outweighing the medical decision making.

The CPT book says, base the level of care off of 2/3 components, BUT all that documentation is not really necessary based on the MDM. Does any one have any recommendations? Do you bill off the 2/3 components, or do you bill the level of care the MDM is supporting?

Thank you,

 

[LLovett]

MDM is not medical necessity

The level of work/documentation should be driven by medical necessity. While MDM is generally one of the key components used to level a visit it doesn't have to be.

I am not a clinical person. Only a clinical person can determine what is medically necessary. If you feel the providers are padding documentation to get higher levels refer it on to who ever is above them clinically. Explain your concerns and let them review it and make a determination. If they think it is ok, then you are covered. If they agree with you then they need to address this with the providers.

Good luck,

Laura, CPC, CPMA, CEMC