Using MDM as base for Established Patient E&M

coderlady

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Can anybody tell me if there is documentation somewhere that supports always using the MDM along with either History or Exam in order to come up with an established patient E&M level? For example, patient comes in with a straightforward MDM (99212) but history and exam support a 99213. Do we give a 99213 just because the Hx and Exam support this but Medical Decision Making or medical necessity support a lower level?? Please advise...... Thanks!!!!
 

thelton

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Local Chapter Officer
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Farmington, AR
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CMS stated that medical necessity is the "overarching criterion" when selecting a level of service. The current MAC for our area, Pinnacle, posted an article on their website in August 2008 that stated "The complexity of medical decision making is the primary indicator of the appropriate level of service". It further stated "....at least 2 of 3 key components must be met for subsequent hospital or established patient E/M services. One of those key components is the level of medical decision making". We are trying to find out how our new MAC (Novitas) will audit claims. I hope this helps.
 
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I work for the DoD (OCONUS) and they follow Medicare and the Coding Guidelines for the most part. However, we do have some guidelines that are "DoD specific". The utilization of MDM as a mandatory component of an established patient E&M assignment is one of the rules and is in the Military Health System Coding Guidance. ANd for your example we would have to assign the 99212.
 

Love Coding!

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Laveen, AZ
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I work for the DoD (OCONUS) and they follow Medicare and the Coding Guidelines for the most part. However, we do have some guidelines that are "DoD specific". The utilization of MDM as a mandatory component of an established patient E&M assignment is one of the rules and is in the Military Health System Coding Guidance. ANd for your example we would have to assign the 99212.
Hi I sent you a private message... :)
 
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