Wiki Need 2/3, can exam be thrown out?

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AmandaW

AmandaW

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If I need 2 out of 3 portions of the note to get my subsequent visit level, can exam be thrown out? Can the Dr not document it, and I just count the history and MDM?
 
Yes, that is exactly what 2 of 3 means. You can choose whichever 2 best suit your situation. In my practice, for example, a patient may return a week after her initial visit to go over CT results. The physician does not perform another exam. The return visit is coded based on history & medical decision making only.
 
BUT, MDM NEEDS to be one of those 2 out of 3, right? I know the MDM is what drives the note, but what if I have everything I need in history and exam to meet moderate level, but MDM is lacking to meet moderate?
 
MDM does not have to be one of the 3 elements for established patients. Some practices do require MDM to meet the level as a way of guaranteeing that medical necessity requirements are met in today's world of inflated History and Exam documentation, but this is not part of the CPT or E&M coding guidelines. Personally, I've always felt that requiring MDM to equal or exceed the level can lead to inaccurate leveling because the history and exam are also an important part of provider work. For example, with some presenting problems, a more extensive history or exam is necessary just to reach the correct diagnosis that they patient does not require further tests or treatment - in such a case the provider would be effectively penalized for the work simply because the MDM was of a lower level than the other elements.
 
We have two third party auditors working with us to improve coding processes. Both said MDM has to be counted, but a recent MAC webinar I attended specifically said it could be dropped if it was the lowest :confused:
 
I believe there is one MAC that requires MDM to be one of the two. There may be some commercial payers that may have that requirement. The practice can also make a policy that MDM has to be one of the two. Other than than that there is no rule about MDM.

Of course as stated above Medical necessity is key.You can easily get a comprehensive history and exam by padding the note on a splinter in the finger but that level would not be medically necessary based on the presenting problem.
 
Last edited:
ellzeycoding said:
Medical necessity is key. Medical decision making is one of the three key components. They are not one and the same.

Let me repeat... Medical Necessity does not equal Medical Decision Making...

Here is a nice article that covers some of the differences...

https://www.racmonitor.com/warning-medical-decision-making-and-medical-necessity-not-one-and-the-same
Click to expand...

A physician examines a new patient at an assisted living . Pt is complex and fits the criteria for a 99328 , highest level. But the Code also says that provider typically spends 75 minutes by the bed side. if the provider only spent 60 min does it mean that he must bill a lower level.
 
nkh786finance@yahoo.com said:
A physician examines a new patient at an assisted living . Pt is complex and fits the criteria for a 99328 , highest level. But the Code also says that provider typically spends 75 minutes by the bed side. if the provider only spent 60 min does it mean that he must bill a lower level.
Click to expand...


Two different ways to meet.

1) based off key components, ignoring the time specified in the code.
2) based off time w/ 50% of the time specified and time was spent doing counseling and/or care coordination.
 
If the documentation supports the higher level with out using time it would be acceptable, remember it is either key components or time but not both.
 
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