MDM and Medical Necessity Questions


Phoenix, AZ
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Hi everyone, I recently started my first coding job!!!

The biggest that has been tripping me up is MDM and medical necessity

For the number of dx or treatment options, the points are given for dx that ARE CURRENTLY being treated right? For example, if someone is being seen for type I diabetes but they have another chronic disease, such as Austism and/or cerebral palsy that is mentioned and in the dx list BUT it was not treated or addressed. Does this get a point just for being a stable, chronic issue? Or no because it has nothing to do with, in this case, the endo clinic visit for f/u of type 1 DM?

Regarding the risk chart, would the issues above contribute to risk--2 or more stable chronic illnesses, etc?

I was also told that, using this same example, that if a provider is billing a 99214 but the coding comes out to C,C,L AND the patient has been seen within 6 months and that visit was also a 99214 and this current visit had little/no workup and they wanted to follow up with them in another six months that you would look at necessity and bill that 99214 instead of 99215. Same goes for if the physician down or upcodes. Is this just something you get used to based on your specialty that you code and your facility?

(I work in pro-fee at a hospital but code clinical endo)

I hope I made everything clear :p Thanks


True Blue
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MDM is probably the most difficult area of E&M because as coders we don't really have the clinical experience to understand what's involved in a provider's decision, and providers typically don't spell it out in detail for us. I've been doing this for years and it still trips me up!

You're correct, you should only count the diagnoses that are being treated, or that affect treatment. Just having it on a list of conditions that the patient has doesn't mean it's a part of the MDM. The documentation should reflect that the condition played a role in the MDM, e.g. the provider evaluated the condition, commented on the status, included it in the treatment plan, etc. In your example, if your provider is just managing the DM, that's one condition, but they may comment that the patient's cerebral palsy is stable and on a medication being managed by another MD, that can show that they are taking this into consideration as a comorbidity in their plan and would warrant counting as an additional point.

Regarding medical necessity and changing code levels - this is a controversial area, and your organization should give you guidance as to how they want you to do this. CPT code guidelines define what elements are required to meet a given code. To reduce the coding to a lower level even when the required elements are present essentially means you're deciding that something that was documented wasn't medically necessary. In the world of electronic records and copy and paste, this is often probably true, but defining that is not so easy. If your organization has worked out this particular framework for when to change a 99215 to 99214 based on the criteria that you that you describe, then hopefully this is something that has been developed over time in discussions with providers and from experience with audits. If that's the case, then I would feel comfortable with it.