Moderate MDM

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My providers feel we are under coding many of their visits. They feel any visit where they prescribe medication can be considered Moderate Risk. So if a child comes in with an OM and they prescribe medicine, it can be considered moderate MDM making it much easier to reach that level 4: Dx/Treatment 3 points New Problem with no add'l W/up & moderate risk for prescribed medicine. Giving them 2 of 3 MDM requirements. I am concerned that if every OM starts being billed as a level 14, it will throw up a red flag to insurance companies for overcoding. Granted I do not want them losing out on revenue deserved, just don't feel every OM should be considered level 14. I feel they need to take on a case by case issue. If there is fever involved or other modifying factors. Am I over thinking this? When I think about prescription drug management, I don't think of antibiotics for ear infection. I get it that MDM can be very subjective and there is no real clarity on what cms wants.
 

thomas7331

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I agree with you on this - I don't believe that simply writing a prescription is sufficient to qualify as moderate level risk. The E&M documentation guidelines specifically say that the table of risk 'includes common clinical examples rather than absolute measures of risk' and is not meant to be used to justify assigning the same level of risk for every situation. The level of risk should be assigned based on the provider's assessment of the individual patient's condition based on 'risk related to the disease process anticipated between the present encounter and the next one' or 'the risk during and immediately following any procedures or treatment' and this should be also reflected in the documentation. A practice I worked with recently conducted an internal audit using a professional coding consulting firm which also supported this approach - they advised us that many large payers consider a visit with a single problem addressed and a prescription written to qualify only as a level 3 visit unless there are other risk factors documented.
 
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Thank you Thomas for your input and advice. I have another question and may seem silly, but if your providers billed out a 99213 and you reviewed the notes and felt that it can be upcoded to a 99214, how would you go about it? Do you just append the note and put in the new charge or do you send it back to the provider to change? I normally send it back for them to correct, is this necessary? Am I allowed to just change it on my own? I am a CPC, not sure credential wise where my limits lie.
 

Pathos

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MDM is one part of E/M

1) Don't forget that the MDM is only one of the three required for an E/M visit. Was the History or Exam portion also at least Detailed? In my practice we have the MDM as the main driver of the visit, and use either the History or Exam as the second required component.
As far as justifying writing an Rx with a "New Problem to the provider", the MDM does support it, however is it medically necessary to throw a script at every OM? This would be an ethical question to the provider. However, I think that as a coder it should be ok. Also, don't forget the associated risks a provider takes by prescribing the medication. Just look at the prescription instructions and you can see all of the potential side effects associated with any medication use.

2) I think that largely depends on your agreements with your providers. We have some who are fine with changing their levels to a higher code, and some who wants to review before making any changes. We work with (and some times for) the providers, and they are held responsible for their billings/coding. But I would be hesitant to just change a provider's code without a pre-arrangement first.
 
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"Management" vs "Writing 7-10 day Rx" Mod risk?

Having experienced a CMS audit of E/M services, I can tell you flat out with certainty that CMS does NOT consider writing a script for a 7-10-14 day Rx "prescription drug management" in all cases and an automatic "moderate" risk. The circumstances of the whole patient encounter must be considered. The example above of OM, is an excellent one. If the patient is typical, for an established patient, an EPF Hx, EPF exam (including vitals and HENT) and an Rx is written without having to consider any other chronic medications or conditions. Documenting a more complex history and exam would not be medically necessary in this scenario and therefore not counted. So even if your provider believes any RX writing is Moderate Risk, you still have a self-limited/minor problem, maybe a lab test, but OM typically in children is considered an uncomplicated illness. EPF, EPF, MOD = 99213. In the same scenario where the patient is new, a more extensive History would be approved for medical necessity such as Detailed or even Comprehensive, the exam would likely be approved for EXP or Detailed. If a script is written for a short term antibiotic, whether you think it's Moderate or low, the code would be the same. New patients require the medically necessary documentation "meet or exceed" 3 of 3 so you have Comp, Detailed, Mod which = 99203

OM in an older more medically complex patient MIGHT meet the requirements of "prescription drug management" because the provider would be considering other existing long term medication therapies when choosing a particular short term antibiotic for treatment. Take away here, Medical Necessity is the Overarching Criteria driving the code. All aspects of the encounter must be considered with that in mind. Simply counting points will not win you points in a payer audit.

Thank you for reading and considering,
AJ - 37 year pro-fee auditor veteran
 
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