Wiki MDM as 1 of the 2 key components

[pygreen]

Does anyone have any specific documentation from either Cahaba or CMS stating that MDM must count as 1 of the 2 key components when auditing an established patient E/M? Please provide the link if you have anything so I can show it to our providers.

Thanks.

 

[MnTwins29]

You can try this one, but I feel it is unclear, as the person submitting the question acutally asked two, but the first word of the answer is "no." No to which one?

CMS never has published anything that specifically says one of the two much be MDM. I have heard certain MAC's may require it, but I have not seen this myself.

http://www.cahabagba.com/faqs/the-a...ve-and-exam-is-documented-to-high-but-mdm-is/

 

[pygreen]

Thanks Lance. I saw this, and I was also uncertain which questions they were answering "No". I interpreted it to mean, no they could not bill 99215 when the MDM was 99214 since medical necessity would not be met.

 

[HOLLYGIFFIN]

There is no such documentation that I am aware of. However, it is our policy to require our physicians to focus on the medical decision making when deciding the level of coding because that piece is really a solid documentation of the level. Payors are requesting documentation on our higher level E&Ms and making an argument that a complete ROS or comprehensive exams are not medically necessary for certain diagnoses. They cannot make that argument with the MDM.

Hope that helps.

Holly Giffin, CPC
Physician Coding Auditor

 

[MnTwins29]

Peggy, I see where you are coming from and that would be correct if the "no" answer is to the first question - but if it is for number 2, then that just says what we all know and it is medical necessity.

I like Holly's approach to this question. While not making it a policy or referring to a hard-and-fast rule, she emphasizes the best way to show the medical necessity of the services, which is what all payors are looking for. I am little less hard-core in my talks with the doctors, but I generally say the same thing - check your MDM as that will be the best way to justify medical necessity for the service.

 

[pygreen]

Thanks Lance. I saw this, and I was also uncertain which questions they were answering "No". I interpreted it to mean, no they could not bill 99215 when the MDM was 99214 since medical necessity would not be met.