Wiki MDM and CMS HELP

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mmunoz21

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HI,

I have a group of Transplant surgeons who brought up a point regarding MDM.
They want me to SHOW them in writing where CMS states that the "MDM" has to be one of the 3 components when choosing the level of service for an established patient.. I've looked and looked and cannot find anything in writing..

We all know that medical necessity is the overarching criterion for payment..
But these doctors are sticking to the 2 out 3 being History and Physical Exam, until SHOWN in WRITING Otherwise..

Your responses are greatly appreciated
 
mmunoz21 said:
HI,

I have a group of Transplant surgeons who brought up a point regarding MDM.
They want me to SHOW them in writing where CMS states that the "MDM" has to be one of the 3 components when choosing the level of service for an established patient.. I've looked and looked and cannot find anything in writing..

We all know that medical necessity is the overarching criterion for payment..
But these doctors are sticking to the 2 out 3 being History and Physical Exam, until SHOWN in WRITING Otherwise..

Your responses are greatly appreciated
Click to expand...

I know this is coming - or at least would bet on it coming. But I have not heard where this has taken into practice by CMS. I know some practices are requiring it as part of their own practice, but I am 90% sure there is nothing that has put the driving force of an E&M as the MDM into play.

So, i'm happy to be wrong, but I don't think that you will find anything at this moment in time about being required to choose the MDM as one out of the 2 elements.
 
Maybe throw this article at them http://www.physicianspractice.com/blog/selecting-right-em-codes-your-medical-practice

Or this http://www.cms.gov/Outreach-and-Edu.../downloads/eval_mgmt_serv_guide-ICN006764.pdf

It says on page 4 and 5
"In addition to the individual requirements associated with the billing of a selected E/M
code, in order to receive payment from Medicare for a service, the service must also be
considered reasonable and necessary. Therefore, the service must be:
❖ Furnished for the diagnosis, direct care, and treatment of the beneficiary’s
medical condition (i.e., not provided mainly for the convenience of the beneficiary,
provider, or supplier); and
❖ Compliant with the standards of good medical practice.
 
Last edited:
Your doctors are right.

Medical Decision Making IS NOT the same as medical necessity. CMS does not require it to be 1 of the key components used to determine the level of service for an established patient. Generally speaking it is a good indicator of the level of service. Generally speaking the presenting problem is indicative of the medical necessity.... but not always, and there is no rule saying MDM has to be used.
 
Agree with Mike. I've read a lot of huff and puff from payers that MDM "should be" and "will be" a driving factor on E/M codes, but nothing has been set in stone as of yet that I have read.

CMS says you need 2/3. CMS does not say MDM has to be one of those 2.

Agree with Mike again on necessity not being equal to MDM. Medical necessity drives the service that was provided. MDM is the measurement of the actual cognitive labor required by a provider to "put the puzzle together" and provide care for the patient.
 
Mdm

I'm going to be swimming against the current of responses here, but Medicare most definitely refers to Medical Decision Making in the Department of Health & Human Services Centers for Medicare and Medicaid Services, Medicare Learning Network (Official CMS Information for Medicare Fee-For-Service Providers) EVALUATION AND MANAGEMENT SERVICES GUIDE. Starting on page 16 and it also defines Risk that needs to be considered in MDM. https://www.cms.gov/Outreach-and-Ed.../downloads/eval_mgmt_serv_guide-icn006764.pdf

Lori Julian
Professional Billing Compliance Manager
CMU College of Medicine
 
I personally disagree with requiring MDM to be 1 of the 2 in a 2 of 3 code. I have seen facilities make that determination and I have seen a few payers say it is required. I have yet to see any CMS or MAC publish something stating it is required. I know I have posted similar links before but below is a link to a CERT audit where the CERT auditors stated the provided under coded. The CERT rationale was based on history and exam, MDM actually supported the level the provider chose. They also cited the link to the MLN E/M Guide posted by Lori above me to support their position.

http://www.wpsmedicare.com/j8macpartb/departments/cert/internal-medicine-spec11.shtml

Billed CPT 99231. Submitted documentation supports up code to 99232 with expanded problem focused history, detailed exam and low complexity MDM.

Laura, CPC, CPMA, CEMC
 
Lori Julian said:
I'm going to be swimming against the current of responses here, but Medicare most definitely refers to Medical Decision Making in the Department of Health & Human Services Centers for Medicare and Medicaid Services, Medicare Learning Network (Official CMS Information for Medicare Fee-For-Service Providers) EVALUATION AND MANAGEMENT SERVICES GUIDE. Starting on page 16 and it also defines Risk that needs to be considered in MDM. https://www.cms.gov/Outreach-and-Ed.../downloads/eval_mgmt_serv_guide-icn006764.pdf

Lori Julian
Professional Billing Compliance Manager
CMU College of Medicine
Click to expand...

I don't see anything in this that states that MDM has to be one of the 2 out of 3 elements to qualify a level. This section just explains how to come up with the MDM level (which is completely different than medical necessity).

I agree that there is a confusion between MDM and medical necessity. Medicare says that medical necessity is the over-arching element for the decision to bill a level. Medical necessity is NOT MDM. I believe what they are trying to say is that if it is medically necessary to do a comprehensive history and exam, then it would be appropriate to bill a higher level for an established patient, even if the MDM is moderate or low. However, it is not appropriate to perform a comprehensive history and exam just to bill the higher level if it is not medically necessary.

I guess this is one of the great debates with E/M coding! It is right up there with what can or can't be counted towards the HPI and the ROS without being considered double dipping! It all boils down to what does the MAC that processes your claim consider in these instances. Life would be so much easier if there was a standard across the board for all MAC's for these issues instead of each coming up with their own idea of what needs to be documented! I have been coding E/M for over 14 years now under Highmark/Novitas and have recently moved and am now coding for a company under a different MAC and it is like learning it all over again! Everything I thought I knew is completely different!

I'm interested in hearing how this debate goes on! :)
 
Hello,
Even though this is an old post, I felt like I should add to this for future readers. It is a concrete fact that #1. Medical Necessity is not the same as MDM and #2. That their is nothing it writing from CMS giving MDM more authority than other key components. The reason why they are not the same can clearly be show with the example of transplant surgeons. Their patients are on immuno therapy which can cause a multitude of complications, so when seen for follow up the surgeon needs to take a higher history and exam to make sure there are no complications. If they didn't, they could miss something serious and in some cases it could be life or death. So even if the MDM is SF when nothing ends up being wrong, the History and Exam is still Medically Necessary. Going by MDM can result in undercoding, which per CMS, can be considered just as fraudulent as overcoding(though rarely enforced).
 
Excellent examples

Thanks Alex for the examples of where MDM may be low but there would be medical necessity for higher levels of history and exam.
 
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