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Selection of E/M

  1. #1
    Question Selection of E/M
    Medical Coding Books
    I was under the impression that when selecting your e/m code that MDM had to be one of the 2 criteria met when 2 out of 3 needed.(99212-99215) Am i wrong? Can it be the HPI and PE? thanks

  2. #2
    Default
    When selecting your e/m level on an established patient, you do not need the MDM. If the HPI & Exam will give the provider a higher level e/m, you do not need to base the e/m on MDM (per our carrier). It might all depend on your carrier.

  3. #3
    Location
    Salt Lake North
    Posts
    691
    Default MDM Drives Medical Necessity
    In an Established Patient visit, I think that MDM should be one of the two. The reason for this is that MDM drives "Medical Necessity". If a young patient comes with with a cheif complaint of an earache, are you going to do a Comp History and a Comp Exam? No. That would be over-kill. How could you defend doing this in light of Medical Necessity? Was it necessary to review all of those systems? No. Your overall code selected should not be higher than MDM as a general rule. If it is, you need to be able to defend yourself in an audit stating why all the systems were reviewed.

  4. #4
    Default Mdm
    Hey qcoder....thanks for your response. Thats exactly what i thought but there seems to be a difference of opinion among many coders. If you only go by hpi and pe your codes could get quite high even though it really wasn't necc to check as many os/ba as listed in documentation. I think i'm going to stick with the way i have been handling it. Thanks for the input! :d

  5. #5
    Location
    Salt Lake North
    Posts
    691
    Default
    To be honest, it's fairly easy to get Moderate Medical Decision Making (Two stable diseases, Rx drug management) which opens you to everything except a level 5 visit. And your not going to do too many of those anyway.

  6. Default Medical Decision Making
    It seems medical decision making is the breaking point with many unanswered questions. Our facility requires that one of the two must meet in medical decision making. I also get a little confused on why putting a patient on a prescription alone should justify a level four when there is a huge difference on drug management of an antibiotic vs. pain medication, or for a chronic condition with other modifying factors. I also get confused on what constitutes acute illness "with systemic symptoms". This is such a gray area to train providers on and it is a 50/50 split depending on what state you are from, or who the information comes from. Some providers believe just because they write a script they can bill a four, but I don't feel comfortable with that. IS there any easy way to decifer this issue?

  7. #7
    Unhappy
    Carrnr1- I totally agree with you on the drug management issue. I code for clinics owned by a regional hospital and someone was hired (a Dr turned coder turned consultant) to instruct us that drug management could make any new problem a 99214. It doesn't matter if it's an antibiotic ointment for a rash or nitro for chest pain. Now most of our Family Practice, Internal med docs have 90% 99214. I think it's crazy and to be honest, after 6 years of coding, I'm having second thoughts as to whether I want to continue in this field.

  8. #8
    Location
    Daytona Beach, FL
    Posts
    752
    Default
    Writing an RX gives you a RISK of Moderate. This does not gaurantee that this will give you a MDM of Moderate Complex or a guarantee of a level four visit. You must also take into consideration the other 2 compontents of MDM. If you are managing at least 3 established problems that are stable, or seeing the patient for a new problem with no additional work-up, then yes, your MDM would be Moderate, or if they are ordering and personally reviewing tests or records, that could also make your MDM moderate, but just saying that if the physician writes an RX makes it automatically a 99214 is not correct.

    As far as the management of an RX, any prescription carries with it a risk, whether it is an antibiotic, skin cream or pain medicine. The patient has a chance of having a bad reaction to any drug, or if it does not work as planned, the physician incurs the extra work of correcting the RX. At our facility, if the patient does not get better on the RX given, the patient can call or may have to come back in for a new RX and that visit is not billed, so there is more work involved for the physician when he writes an RX. So, I feel that writing an RX is correct to be considered Moderate risk and to help in obtaining a higher E/M level.

    Also, even though the MDM is supposed to be the driving factor in your level, the guidlines say 2 of the 3 must meet or exceed and it does not state that one of those components must be MDM. So in answer to Helen's question, technically, yes it could be HPI and Exam. I would however question a level 5 for an ear ache, but I could see a level 4 under the correct circumstances.
    Last edited by jdibble; 10-14-2010 at 07:36 AM.
    Jodi Dibble, CPC

  9. #9
    Location
    Stuart, Florida
    Posts
    331
    Default
    Quote Originally Posted by qcoder View Post
    In an Established Patient visit, I think that MDM should be one of the two. The reason for this is that MDM drives "Medical Necessity". If a young patient comes with with a cheif complaint of an earache, are you going to do a Comp History and a Comp Exam? No. That would be over-kill. How could you defend doing this in light of Medical Necessity? Was it necessary to review all of those systems? No. Your overall code selected should not be higher than MDM as a general rule. If it is, you need to be able to defend yourself in an audit stating why all the systems were reviewed.
    I completely agree, qcoder.
    E/M has got to be my least favorite part of being a coder. It's so very subjective. Honestly, the first thing I take into account when selecting an E/M code is MDM. I find it easier to make a code selection by working backwards.
    Vanessa Mier, CPC

  10. #10
    Location
    Cincinnati, Ohio
    Posts
    31
    Smile
    Quote Originally Posted by jdibble View Post
    Writing an RX gives you a RISK of Moderate. This does not gaurantee that this will give you a MDM of Moderate Complex or a guarantee of a level four visit. You must also take into consideration the other 2 compontents of MDM. If you are managing at least 3 established problems that are stable, or seeing the patient for a new problem with no additional work-up, then yes, your MDM would be Moderate, or if they are ordering and personally reviewing tests or records, that could also make your MDM moderate, but just saying that if the physician writes an RX makes it automatically a 99214 is not correct.

    As far as the management of an RX, any prescription carries with it a risk, whether it is an antibiotic, skin cream or pain medicine. The patient has a chance of having a bad reaction to any drug, or if it does not work as planned, the physician incurs the extra work of correcting the RX. At our facility, if the patient does not get better on the RX given, the patient can call or may have to come back in for a new RX and that visit is not billed, so there is more work involved for the physician when he writes an RX. So, I feel that writing an RX is correct to be considered Moderate risk and to help in obtaining a higher E/M level.

    Also, even though the MDM is supposed to be the driving factor in your level, the guidlines say 2 of the 3 must meet or exceed and it does not state that one of those components must be MDM. So in answer to Helen's question, technically, yes it could be HPI and Exam. I would however question a level 5 for an ear ache, but I could see a level 4 under the correct circumstances.


    Well said Jodi! I wholeheartedly agree. Until I see in writing that CMS or my state carrier is requiring MDM to be one of the 2 components for subsequent visits I will not impose that requirement when auditing. That is not to say that I wouldn't question high level documentation/coding for a relatively "minor" problem.

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