Question MDM Complexity

cfwh671

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The rule for E/M auditing is, it only takes two out of three elements to qualify for any level of MDM. But what if the Number of Dx or treatment options is Extensive (4 points), the Risk of complication is Moderate, and the Amount and complexity of data is Minimal/Low (1point).
Would this visit be Straightforward, Moderate, or High complexity?
 

Pathos

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Based on what you are presenting:
  • Dx/Mx Options: 4 points
  • Risk: Moderate (3 points)
  • Data: 1 point
As you state, the Overall MDM is based upon two out of the of the highest three MDM components. In this case, Dx/Mx Options and Moderate Risk would suggest that the Overall MDM is of Moderate Complexity.

All things said, don't forget that Medical Necessity will trump over any quantified model/tool, even the Marshfield Clinic tool you used.

CMS E/M guidelines
 

cfwh671

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Based on what you are presenting:
  • Dx/Mx Options: 4 points
  • Risk: Moderate (3 points)
  • Data: 1 point
As you state, the Overall MDM is based upon two out of the of the highest three MDM components. In this case, Dx/Mx Options and Moderate Risk would suggest that the Overall MDM is of Moderate Complexity.

All things said, don't forget that Medical Necessity will trump over any quantified model/tool, even the Marshfield Clinic tool you used.

CMS E/M guidelines
Thank you so much! The insurance company I sent the claim to is downcoding the CPT level from a 4 to a 2, so this will help me greatly in building my argument in the appeal.
 

Pathos

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You're welcome!

Auditing is based upon documentation, which means anything billed and submitted must be properly supported. Ensure the documentation is correctly qualifying for the right levels in the MDM. There are some limitations under the Dx/Mx Options, and there is a certain element of interpretation in the Risk Table as well.
 
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