Wiki OIG suggestion for choosing E/M level

[gfarrell]

I have heard the the OIG is strongly suggesting how to choose an E/M level. We already know that the AMA / CPT state an established patient only needs 2 out of the 3 components to meet the E/M level. I understand that the OIG is suggesting/weighing more on the MDM component and that they "strongly suggest" that the MDM should be one of the 2 components to declare the E/M level. I want to bring this info to my provider but I know he will want hard fast documentation and I cannot find it on the OIG website. Can anyone provide me with the link to a current document from the OIG about this? Your help is greatly appreciated!

 

[mdoyle53]

I have not seen anything about this from the OIG. However, I agree that the MDM should be a driving factor in choosing a code. This relates back to the reason the patient is there or the 'Nature of the Presenting Problem'. For an E&M visit, it is legal to use the Hx and Ex but then I would question whether the medical necessity drives the actual code. Almost every insurance company indicates in the contract that you will only perform medical necessary services to the members - hence that can somewhat be directed to MDM - but not in all circumstances.

 

[melzinser]

Not just the OIG...

CMS has previously stated for awhile that documentation alone shouldn't drive the selection of an E&M code, only support it.

"Medical necessity of a service is the overarching criterion for payment in addition to the individual requirements of a CPT code." (see CMS Claims Processing Manual, section 30.6.1 - Selection of Level of Evaluation and Management Service, Rev. 2373, 12-21-11) https://www.cms.gov/manuals/downloads/clm104c12.pdf

The OIG position is due to the realistic fear of automatic overcoding with 'point & click' and 'cut & paste' EHR's.

 

[dclark7]

Anthem Blue Cross of CT updated their documentation guidelines effective 12/1/11. They now require MDM as one of the two components to determine the E/M level for established patients. I wouldn't be surprised if others start doing the same thing.