MDM level - Can anyone point me to CMS guidelines


True Blue
Overland Park, KS
Best answers
Can anyone point me to CMS guidelines that state you can't bill higher than the MDM level? For example:


You have to go with the MDM for the level.



You would go with the exam for the level

Is this correct and where in the CMS guidelines does it state this? Another auditor told me this and I want to confirm this. Thanks.
I wish I could give you a specific black and white printed answer, but that would make life to simple. What I do know is that Dr. Deborah Patterson, the medical director for my MCR carrier (Trailblazer) stated that medical necessity is always the driving factor. Yes, I know that coding rules say on subsequent visits you can use 2 of 3 to determine your level, but she emphasized that you need 2 of 3 and one of the three has to be MDM. If you don't stick with MDM, then you could document a really good history and exam for a "cold" and call it a high level visit. You didn't specify what type of visit, if it is an initial you must meet all three criteria to bill a level, the code is then based on whichever element is the lowest.
"but she emphasized that you need 2 of 3 and one of the three has to be MDM." It would be great if you can share the documented evidence for this.
Let me try to rephrase my question here:

If it is a new patient, per the guidelines all three levels must meet. If they don't meet, then you go with the lowest level. I understand this. What if it is an established patient? If you can't bill higher than your MDM level; then if you have an EPF history, a detailed exam, and MDM is high; you bill based on the exam level. Correct?


For an established patient, the history level is detailed, the exam is detailed, and MDM is SF; then you bill based on the MDM level because it is the lowest. Correct?
For the established patient you must meet or exceed 2 of 3 key components - one being in your first established patient example, the level of service would be 99214 (detailed exam and high MDM). In your second example, I would code as 99212 because of the MDM. The way I look at it, the MDM supports the medical necessity of the exam. Hope that helps...just my opinion in a highly debated area. :)
I agree that MDM always drives the final level of service. But, anybody, please help me if there is any documented evidence from CMS or any of its carriers that; for an established patient when we are considering only 2/3; we have to consider MDM as one of the salient feature. Because lot of established patients' charges we are coding will have minimal MDM or sometimes completely MDM will be missing; and we are assigning the level based on History and PE.
CMS documentation

Pub 100-04
Medicare Claims Manual, Chapter 12 30.6.1 Selection of level of Evaluation and Management Service

A. (second Paragraph) "Medical necessity of a service is the overarching criterion for payment in addition to the individual requirments of a CPT code. It would not be medically necessary or appropriate to bill a higher level of evaluation and management service whena lower level of service is warranted. THe volume of the documentation should not be the primary infulence upon which a specific level of service is billed. Documentation should suppoert the level of service reported. The service should be documented during or as soon as practicable after it is provided in order to maintain an accurate medical record."

Hope this helps.
Just received the June Coding the Letters to the Editor, there is a letter from a coder disagreeing with the "5th commandment" from the article in the February Coding Edge. The letter and the response are very interesting...helps explain/interpret Medicare policy.
Dr Spain

I agree and does any one else notice that he is saying the same thing as CMS and the physician from EM University website? Which some great coding info tools by the way.
I pulled out the 2008 AMA CPT book in the E/M service guidelines under "Select the Appropriate Level of E/M" it states...
For the following categories/subcategories, two of the three key components (ie, history, examination, and MDM) must meet or exceed the stated requirements to qualify for a particular level E/M services: office, est. pt; subsequent hospital care; subsequent nursing facility care; domiciliary care; established patient; and home, established pt.
Although it does not state that one of the 2 must be MDM I personally would suggest that it be.
Hope this helps