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Thread: 2 out of 3 for established E/M

  1. #1

    Default 2 out of 3 for established E/M

    AAPC: Back to School
    I read somewhere that when determining cpt code level on an established patient visit (2 out of 3) MDM must be 1 of the 2 elements to determine level of service. has anyone else heard of this or better yet know where I would be able to find documenation preferably from Medicare/CMS confirming this.

    Thank you,
    Kristin B.

  2. #2
    Join Date
    Apr 2007
    North Carolina


    Depends on who you listen to and the policy of your carrier.

    Medical necessity of a service is the overarching criterion for payment in addition to the individual requirements of a CPT code. It would not be medically necessary or appropriate to bill a higher level of evaluation and management service when a lower level of service is warranted. The volume of documentation should not be the primary influence upon which a specific level of service is billed. Documentation should support the level of service reported. The service should be documented during, or as soon as practicable after it is provided in order to maintain an accurate medical record.

    MDM is obviously important and one might raise an eyebrow if you have a straightword MDM yet comprehensive history/exam; however, this will become a medical necessity issue.


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