Wiki Medical decision making

[WFassnacht]

Is medical decision making still the overarching factor when you go to determine your level of care. If this has changed can you please provider me with a website.

 

[MikeEnos]

Medical Decision Making NEVER WAS the "overarching criterion for payment." You're thinking of medical necessity. Those to terms do not mean the same thing, and are not interchangeable.

 

[suemt]

I don't see where the question has anything to do with payment.

It is true that you can do HPI and exam til the cows come home, but your MDM needs to support the level of service you wind up billing.

An exception (of course there is always an exception!) would be time-based coding.

 

[MikeEnos]

I was completing the quote, Sue. The OP used the term overarching factor, in the context of asking about medical decision making determining the level of care. That phrase is based on an actual quote from CMS Claims Processing Transmittal 100-04-178 regarding the selection of a level of evaluation and management service:

30.6.1/Selection of Level of Evaluation and Management Service
A - Use of CPT Codes
Advise physicians to use CPT codes (level 1 of HCPCS) to code physician services,
including evaluation and management services. Medicare will pay for E/M services for
specific non-physician practitioners (i.e., nurse practitioner (NP), clinical nurse
specialist (CNS) and certified nurse midwife (CNM)) whose Medicare benefit permits
them to bill these services. A physician assistant (PA) may also provide a physician
service, however, the physician collaboration and general supervision rules as well as all
billing rules apply to all the above non-physician practitioners. The service provided
must be medically necessary and the service must be within the scope of practice for a
non-physician practitioner in the State in which he/she practices. Do not pay for CPT
evaluation and management codes billed by physical therapists in independent practice
or by occupational therapists in independent practice.

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. The service should be documented during, or as soon as
practicable after it is provided in order to maintain an accurate medical record.

Given the context of the question, I wanted to make clear that the medical decision making is not the overarching criterion, and it never was. CMS states that the medical necessity is the overarching criterion. Be aware that those two phrases are not the same, and are not interchangeable.

While you are correct that theoretically the provider could always document a comprehensive history and exam, that doesn't mean they are all level 5's - the medical necessity should determine the level of service. That does NOT mean that the medical decision making complexity limits the level of service. Just answering the question: "Is medical decision making still the overarching factor when you go to determine your level of care?" No - it isn't, and it never was.

 

[mitchellde]

well put Mike!