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Thread: Correct understanding of 3 key components for f/u codes

  1. #1

    Default Correct understanding of 3 key components for f/u codes

    AAPC: Back to School
    Which of these scenarios is correct per Medicare?:
    a) to bill a 99211-99215, all 3 key components must be documented (hpi,exam and mdm) but you only need to consider the 2 highest to choose the LOS
    b) only 2 of those 3 must be documented and obviously would choose LOS on what it is since there is only 2?

  2. #2


    All 3 factors - history, exam, MDM must be documented to choose an E and M code;
    Lavanya Mohan

  3. #3
    Join Date
    Apr 2007
    Boston, MA


    Both statements are correct.
    If all three are documented the two highest (or the one in the middle) will determine the code.
    However, there are times when (for example) an exam may be deferred. In that case you only have History and MDM to determine the level and that's OK also.
    In addition, if the patient came in for counseling - let's say s/he had radiology tests and those came back with problems - the MD may give a quick history, not repeat an exam at this point, document a good amount of MDM but spent a long time with the patient going over the results and implications and discussing/developing a treatment plan. In a situation like that your provider should indicate the amount of time spent with the patient and how much of it was for counseling. You could find your level based on the time.

  4. #4
    Join Date
    Apr 2007
    Greeley, Colorado


    I completely agree with Karolina.
    Lisa Bledsoe, CPC, CPMA

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