Page 1 of 2 12 LastLast
Results 1 to 10 of 14

What E/M code woud you allow in Audit?

  1. #1
    Location
    New York State Capital District Professional Coders, Albany, NY
    Posts
    12
    Question What E/M code woud you allow in Audit?
    Medical Coding Books
    Our Practice is doing an extensive internal audit on E/M coding. A primary care provider documented a detailed history, detailed exam, and low medical decision making on a patient with a cold which is actually resolving. The patient is in their 30's. I realize 2 of the 3 key components meet and support the 99214, but isn't this where nature of presenting illness (the contributing factor) comes into play? I don't think this patient is at a moderate risk of mortality if they left the office untreated. The risk is low or even lower. That's the thought process I use. I'm having a dispute with another Coder on the Team and would like some help with this interpretation. The patient does not have history of Asthma or COPD or any other comorbidities that might influence a higher level of complexity.

  2. #2
    Default
    Medical necessity is the driving factor, but MDM is not what determines medical necessity. It can be a good indicator but it is not the end all be all.

    I have no idea what happened in your case but I use this type of a visit as an example to my providers all the time. In fact I just had my daughter in for the same basic thing yesterday.

    A detailed history is done along with a detailed exam. You have a new problem with no work up (3 pts), obviously no data pts, so it comes down to the table of risk to determine your MDM level. If they give a script at this point you are at moderate. If they don't you are most likely stuck at low (OTC) or even straight forward (rest).

    So the only difference between an undeniable 4 and a 3 or even a 2 is where they fall on the table of risk. They are doing the same work in obtaining hx and doing exam. They have the same dx and work up pts. They have the same presenting problem. If the doctor had written a script you would not even be questioning the level, it would be a straight 4.

    Unless this was a follow up visit, I say the 4 is correct.

    Just my take on it,

    Laura, CPC, CPMA, CEMC

  3. #3
    Default
    Quote Originally Posted by katmryn78 View Post
    Medical necessity is the driving factor, but MDM is not what determines medical necessity. It can be a good indicator but it is not the end all be all.

    I have no idea what happened in your case but I use this type of a visit as an example to my providers all the time. In fact I just had my daughter in for the same basic thing yesterday.

    A detailed history is done along with a detailed exam. You have a new problem with no work up (3 pts), obviously no data pts, so it comes down to the table of risk to determine your MDM level. If they give a script at this point you are at moderate. If they don't you are most likely stuck at low (OTC) or even straight forward (rest).

    So the only difference between an undeniable 4 and a 3 or even a 2 is where they fall on the table of risk. They are doing the same work in obtaining hx and doing exam. They have the same dx and work up pts. They have the same presenting problem. If the doctor had written a script you would not even be questioning the level, it would be a straight 4.

    Unless this was a follow up visit, I say the 4 is correct.

    Just my take on it,

    Laura, CPC, CPMA, CEMC
    Well stated Laura!
    Roxanne Thames CPC, CPC-I, CEMC
    rthamescpci@gmail.com


    "Remember the greatest gift is not found in the store but in the heart of true friends"

  4. #4
    Location
    New York State Capital District Professional Coders, Albany, NY
    Posts
    12
    Default
    This one particular scenario was a follow up visit. Thank you for your response.

  5. #5
    Location
    Dover Seacoast New Hampshire
    Posts
    1,970
    Default
    I agree with the level 4, unless your CMS contractor is NHIC (as is here in NH). They have gone so far as to indicate that MDM should be the determining factor in E&M code selection, when 2/3 key components need to be met.

    Isn't it fun when CMS doesn't agree with CPT?
    Pam Brooks, MHA, COC, PCS, CPC, AAPC Fellow
    Coding Manager
    Wentworth-Douglass Hospital
    Dover, NH 03820

    If you can dream it, you can do it. Walt Disney

  6. #6
    Default
    I know of some companies even adopting policies that have the MDM as the driving factor even with the 2 out of 3. Maybe this scenario/issue can be addressed in the future within your company.

    The physicians I work for elected not to adopt this policy because they are made up of multiple specialties and it wouldn't be fair (lack of a better word) to all physicians. For example, Medical Oncology and Hematology practices.

    Good luck!

  7. Default
    i agree with Laura, great explanation.
    Danielle Carroll

  8. #8
    Location
    Salt Lake North
    Posts
    620
    Default
    If the cold was the cheif complaint and the ultimate diagnosis, I would say that this is over-coded and the doc did too much work. I can see getting an easy Extended HPI especially if the doc knows what elements to focus on. The MDM is low. So the key factor is the exam. I can see getting an EPF exam out of this. But to get to a detailed exam you would need 12 exam bullets. And for a simple cold, I can't see getting 12 exam bullets and saying that all of them are "Medically Necessary".

  9. #9
    Default
    You don't need 12 bullets do get a detailed exam under 95 guidelines. I don't personally like 95 but many times it is more advantageous for the provider and that is what the auditors are supposed to go with, whichever set of guidelines that are more advantageous to the provider.

    Laura, CPC, CPMA, CEMC

  10. #10
    Location
    Overland Park, KS
    Posts
    1,166
    Default
    If this is a follow-up visit for a cold that is resolving, I don't see a level four here. I say a level three hands down.
    Dawson Ballard, Jr., CPC, CEMC, CPMA, CCS-P, CPC-P, CRHC, AAPC Fellow
    Coder

Page 1 of 2 12 LastLast

Similar Threads

  1. E/M Audit - Denver - Need an audit done
    By skneefel in forum Auditing General Discussion
    Replies: 1
    Last Post: 07-23-2013, 08:24 AM
  2. Audit
    By Mindy Davis in forum Emergency Department
    Replies: 3
    Last Post: 06-05-2011, 10:11 PM
  3. Audit help
    By broundy in forum Auditing General Discussion
    Replies: 0
    Last Post: 10-31-2010, 01:48 PM

Posting Permissions

  • You may not post new threads
  • You may not post replies
  • You may not post attachments
  • You may not edit your posts
  •  
Enjoying Our Forums?

AAPC forums are a benefit of membership. Joining AAPC grants you unlimited access, allowing you to post questions and participate with our community of over 150,000 professionals.

Join Now Continue Reading Without Full Access

Already a Member?

Login

Close Message

In addition to full participation on AAPC forums, as a member you will be able to:

  • Access to the largest healthcare job database in the world.
  • Join over 150,000 members of the healthcare network in the world.
  • Be a part of an industry leading organization that drives the business side of healthcare.
  • Save anywhere from 10%-50% with exclusive member discounts on courses, books, study materials, and conferences.
  • Access to discounts at hundreds of restaurants, travel destinations, retail stores, and service providers. AAPC members also have opportunities to save on heath, life, and liability insurance.
  • Become a member of a local chapter and attend regular meetings.