Wiki Medical decision making a key element

[Lynda Wetter]

Hello,
Question: I was trained with the fact that MDM SHOULD be one of the 2 elements in the leveling of an established visit. I know there is no specific guideline stating this but I was wondering if anyone can give some insight on this.
Are there any articles out there someone can suggest?
I believe it is best practice to make the MDM one of the key elements but others do not.
They can meet the medical requirements for a detailed hx and exam but the MDM sometimes is PF or Low. So if for a viral infection they are not giving meds but ordering labs and rest its possibly being billed 99214. You can get a detailed HX in a 4 minutes conversation, I feel a level four is a bit much, any/all opinions welcomed.
Thanks

 

[dtlandry67]

You are correct. CMS instructs: "Medical necessity of a service is the overarching criterion for payment in addition to the individual requirements of a CPT code. It would not be medically necessary or appropriate to bill a higher level of evaluation and management service when a lower level of service is warranted. The volume of documentation should not be the primary influence upon which a specific level of service is billed. Documentation should support the level of service reported". For a simple viral infection- one with no meds prescribed.. that will resolve on it's own you are at a Straightforward level of risk and will never justify a 99214. With nothing else going on that would probably only be audited at a 99212.