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Thread: High MDM help to get 99215

  1. #1

    Default High MDM help to get 99215

    AAPC: Back to School
    Hello everyone:
    I am trying to educate the doctors I am currently coding for and I would like to show them samples of what would be an example of High MDM. Some of them believe that just because a patient has a bunch of chronic problem they can bill a 99215. Most of the patient can easily meet a comprehensive HPI and exam but my MDM most of the time is moderate of course they disagree with me. But is at least they may documented the time or something that they spend counseling, etc. Any help would be very appreciate it. Thanks
    Mildred Nieves, CPC

  2. #2
    Join Date
    Apr 2007
    Kansas City, MO


    Do you have a "table of risk" that you can show them so they can see what CMS themselves have put under that high risk section??

    I audit family practice...and it is rare that I see something that meets the criteria for high risk. They gotta be pretty sick...respiratory distress/severe asthma attack...sever side effect of a medication for a chronic illness...

    In the CPT book there are examples of scenarios for the codes...well there ae in mine, professional edition...there are only a couple for fam practice.
    One says a male- being seen for 3 month hx of weight loss, fever, fatigue w. adenopathy and splenomegaly.
    Other says 70 y/o F w/ DM and HTN, two mo hx of confusion, agitation, and short term memory loss.

    Hope this helps...

  3. #3


    Thanks a lot for your reply I also code family practice I am learning everyday something new, great examples. I appreciate your help.
    Mildred Nieves, CPC

  4. #4


    I agree - the Table of Risk is a great resource for providers to gauge where they fall as far as moderate vs. high risk. I often point out that moderate would be a "mild exacerbation of a chronic problem" and high would be a "severe exacerbation of a chronic problem" (that is just one example)

    Also look at appendix C in the CPT Book - there are a couple of examples for Family/Internal Medicine under 99215. These may be good scenarios to present.
    Christina Musser, CPC

  5. #5
    Join Date
    Apr 2007


    Comprehensive history and exam with moderate MDM is a 99215 for an established patient. Its 2 of 3.

    Also remember on MDM it is 2 of 3, so even if your table of risk is moderate if your dx and data points are each 4 or more that is high risk. Example: Patient with 3 or more chronic issues at least one uncontrolled, they order labs and say an echo plus do an EKG they interpret in the office. You have high risk MDM with out even getting to the table of risk. As with all services they must be medically necessary so they can't just order testing to pad the MDM and get higher levels but if it is medically necessary you can see how easy it is to hit high MDM.

    Laura, CPC, CPMA, CEMC
    Last edited by LLovett; 08-10-2010 at 12:39 PM.

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