Wiki Question on Level of Service

[TMB1965]

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]

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]

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

 

[TMB1965]

The Insurance is Humana Gold Plus Medicare, and as far as I know my company doesn't make the MDM a mandatory component.

 

[trose45116]

i was told that if its 3 of 3 you code to the lowest and if its 2 of 3 you drop the lowest and code to the second lowest

 

[vandycta]

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]

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.