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Compliance question

  1. Default Compliance question
    Medical Coding Books
    If your HPI, Exam and MDM are all different levels for an established patient do you use the lowest level?

  2. #2
    Baton Rouge
    Quote Originally Posted by KLITTLEFIELD View Post
    If your HPI, Exam and MDM are all different levels for an established patient do you use the lowest level?
    No, that is incorrect. For established visit levels, 2 of the 3 must meet the LOS. So if you have Detailed History, EPF Exam, High-Complex. MDM, Overall visit is level 4...99214, because at least 2 of the elements meet the requirements for a level 4 visit--History and MDM.
    Meagan Strauss, CPC, CEMC
    Coding Coordinator
    The NeuroMedical Center
    Baton Rouge, LA

  3. #3
    I agree with Meagan, with the cautionary statement that most places now will consider MDM to be the one that would draw it down.
    I code 2 of 3 to meet the level of service, but for me its
    history and mdm must meet
    exam and mdm must meet
    Melissa Tescher, CPC, CPMA, CEMC Compliance and Coding Specialist
    Willamette Valley Professional Services member National Advisory Board 2013-2015

  4. Smile
    Thank you

  5. #5
    New Windsor, New York
    Default Be careful on the MDM rule
    Be sure to check your payor rules before automatically assuming MDM is one of the two criteria that must be met for a level on established patients. Medical NECESSITY, not DECISION MAKING, is considered the "overarching criteria" for deciding the level, per the 1995 and 1997 Documentation Guidelines from CMS. These are not the same. It is perfectly acceptable and proper to assign 99214 for an encounter with detailed history and exam, but low MDM. The documentation must show the medical necessity for the extra work involved in the detailed history and exam (why would it be done for a simple diagnosis such as pharagitis, for example) but to say that MDM must be one of the two key elements is incorrect unless the payor rules specifically state this.


    Director, Health Information Management
    HealthAlliance of the Hudson Valley
    Kingston, NY

  6. #6
    For established you need only 2/3, so you can drop the lowest. In the case of a new person you'd need 3/3. That's what the guidelines say so that's what we code too.

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