MDM and walking boot

vmassey

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We are presently doing an internal E/M audit for our Orthopaedic office and educating our providers. One of our physicians had a question about DME items as treatment and where that falls on the MDM risk table.

He treated an established patient for Achilles tendinitis and Haglund's deformity. His HPI and Exam were both a Detailed level. The patient was given home exercises and a walking boot. The patient has had pain/discomfort with this foot for 1 year. He also ordered an MRI for the heel to evaluate calcium deposits of the tendon. The auditor chose Low for MDM but the provider feels that a walking boot would be like a cast and should be Moderate.

I am needing further guidance for DME/walking boot items and where they fall on the MDM risk table so I can re-evaluate this case for the provider and provide education for everyone involved.

Thank you
Vicki Massey, CPC
Orthopaedic Sports Medicine Center, Inc
 
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We are presently doing an internal E/M audit for our Orthopaedic office and educating our providers. One of our physicians had a question about DME items as treatment and where that falls on the MDM risk table.

He treated an established patient for Achilles tendinitis and Haglund's deformity. His HPI and Exam were both a Detailed level. The patient was given home exercises and a walking boot. The patient has had pain/discomfort with this foot for 1 year. He also ordered an MRI for the heel to evaluate calcium deposits of the tendon. The auditor chose Low for MDM but the provider feels that a walking boot would be like a cast and should be Moderate.

I am needing further guidance for DME/walking boot items and where they fall on the MDM risk table so I can re-evaluate this case for the provider and provide education for everyone involved.

Thank you
Vicki Massey, CPC
Orthopaedic Sports Medicine Center, Inc

In my opinion, I would agree the MDM is low.

I could be wrong here, but as far as applying DME to MDM, I see that's just way to broad of a categorical relationship to make one blanket statement on how DME applies. Consider this: ordering a boot to help with pain versus ordering a boot to prevent further damage and hopefully spare the patient from being wheelchair-bound (in theory). Clearly the intent has the most impact here. In other words, to what degree is the item "medically necessary"? Helping alleviate pain so the patient can regain function in ADL is certainly necessary, but when compared to preventing a patient from ending up in a wheelchair, the level of that necessary-ness goes way up. Make sense?

I can see where the provider would apply the boot as an equivalent to a cast, but putting on a boot to help with pain isn't quite the same thing as putting on a cast. You can just take the boot on as you please, but not the case if it's a cast, obviously.

Nonetheless, if it's an established patient with a detailed HX and exam, you'd still end up with 99214 despite the MDM being low since you've already met 2 of 3 criteria to qualify for that E/M level. The MDM level wouldn't matter.
 

CodingKing

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In my opinion, I would agree the MDM is low.

I could be wrong here, but as far as applying DME to MDM, I see that's just way to broad of a categorical relationship to make one blanket statement on how DME applies. Consider this: ordering a boot to help with pain versus ordering a boot to prevent further damage and hopefully spare the patient from being wheelchair-bound (in theory). Clearly the intent has the most impact here. In other words, to what degree is the item "medically necessary"? Helping alleviate pain so the patient can regain function in ADL is certainly necessary, but when compared to preventing a patient from ending up in a wheelchair, the level of that necessary-ness goes way up. Make sense?

I can see where the provider would apply the boot as an equivalent to a cast, but putting on a boot to help with pain isn't quite the same thing as putting on a cast. You can just take the boot on as you please, but not the case if it's a cast, obviously.

Nonetheless, if it's an established patient with a detailed HX and exam, you'd still end up with 99214 despite the MDM being low since you've already met 2 of 3 criteria to qualify for that E/M level. The MDM level wouldn't matter.

I agree with your train of thought, pain vs strain vs fracture are on different sides of the spectrum. The only issue with the last line is if there is a payer which requires MDM to be one of the two components, the final level will be lower.
 
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vmassey

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thank you both for your valuable input. Our office leans toward MDM as one of the 2 components when determining the level. I agree if the walking boot was applied for fracture or sprain I would have valued it higher.

We will see if this explanation helps him see the train of thought for each decision.

Again thank you:)
 
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I agree with your train of thought, pain vs strain vs fracture are on different sides of the spectrum. The only issue with the last line is if there is a payer which requires MDM to be one of the two components, the final level will be lower.

It would most definitely impact new patients, initial inpt/observations/etc... but who would prescribe a boot for an admit? :rolleyes:

As far as payer requirements, if you were to say the MDM is moderate, you'd probably have to back that up with documentation, which would likely end up with the same outcome as you have now. Payer requirements are based purely on medical documentation and proof of the necessity. I suppose the worst that can happen is you get downcoded. I'm going to send you a PM with some specifics that I don't particularly want to post for the world to see.
 
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