Question on Level of Service

tmr1965

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For an established patient if the MDM is straight forward does that automatically make the level of E&M a 99212 whether or not you have met the History & Exam? If so can someone please refer me to the guidelines for this to back that up? I was marked off for coding a 99213 where I currently work for that. I thought the lowest of the 3 was eliminated when choosing the level for an EP.
 

colsonccsp@yahoo.com

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Although the CPT guidelines indicate that any 2 of 3 key components be met in order to achieve an established patient level some organizations tie MDM as a mandatory component to set the level because of concern for medical necessity. Does your organization do this?
 

CodingKing

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Some payers have in their payment policy that MDM is required and cannot be thrown out which doesn't match CPT or the DG's
 

vandycta

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MDM not the same as Medical Necessity

I recently watched an AAPC Webinar "E/M Coding Conundrums" where it pointed out the medical necessity, not MDM is the overarching criteria. Documentation of the nature of the presenting problem is a factor in determining medical necessity. Hopefully that helps a bit.
 

CodingKing

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I recently watched an AAPC Webinar "E/M Coding Conundrums" where it pointed out the medical necessity, not MDM is the overarching criteria. Documentation of the nature of the presenting problem is a factor in determining medical necessity. Hopefully that helps a bit.


Yes that's a big one, It means even if you did a Comprehensive History, Comprehensive Exam you can't count them as Comprehensive unless its medically necessary based on the presenting problems. Example is if you have a splinter in your finger there would be no reason to do a Comprehensive History/Exam and if the physician did they would have wasted their time since you did you don't get credit for doing more than Medically Necessary.
 
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