lcterry
Contributor
We had a discussion in our office today about coding for established patients, our doctors only want to use the 2 components of History and Exam, and not MDM.
I have read some where that medical decision making is always one of the 2 of the 3. I attended a seminar where is was told to me also. I need documentation to back us up.
If this is not the case then I need further guidance.
We had an example, of a patient coming in with a sinus infection, and the history and exam met a level 4, but the MDM only met a level 2, and we were told since the history and exam met a 4 we were to code that as a level 4.
I'm afraid if we were audited then we would be dinged for this.
Does anyone have a Medicare link to help with this?
Thanks
I have read some where that medical decision making is always one of the 2 of the 3. I attended a seminar where is was told to me also. I need documentation to back us up.
If this is not the case then I need further guidance.
We had an example, of a patient coming in with a sinus infection, and the history and exam met a level 4, but the MDM only met a level 2, and we were told since the history and exam met a 4 we were to code that as a level 4.
I'm afraid if we were audited then we would be dinged for this.
Does anyone have a Medicare link to help with this?
Thanks