You will get different answers on this. The official guidelines do not state that one of the 2 compoents be MDM BUT some organizations and even at least one local Medicare carrier have taken this conservative stance.
The thing to remember is that the medical necessity is the overarching criteria for any E/M service. MDM is usually a good gauge of this.
I think that the nature of presenting problem needs to be taken into consideration. A provider can document a level 5 established on every paitent with hitting all of the elements of history and exam - the question is "was the comprehensive history and exam warrented" based on the nature of presenting problem.
Medicare Claims Processing Manual Chapter 12 section 30.6.1 states
"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"
In the scenario you are describing it sounds like there could be an justifiable argument either way. I would check with your local Medicare Carrier to find out thier stance on weight of MDM with established patients. If there is nothing posted on their website you can always query them.
Although this was not a straighforward answer I hope this helps
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