Results 1 to 2 of 2

History & Exam outweighing MDM

  1. #1
    Default History & Exam outweighing MDM
    New Call-to-action
    For an established patient visit only two of the three components need to be met in order to obtain a level of care. I have a few physicians that are overdocumenting on the established patient encounters. With an end result of the history and examination outweighing the medical decision making.

    The CPT book says, base the level of care off of 2/3 components, BUT all that documentation is not really necessary based on the MDM. Does any one have any recommendations? Do you bill off the 2/3 components, or do you bill the level of care the MDM is supporting?

    Thank you,
    Tiffany Fischer, CPC, CEMC

  2. #2
    Default MDM is not medical necessity
    The level of work/documentation should be driven by medical necessity. While MDM is generally one of the key components used to level a visit it doesn't have to be.

    I am not a clinical person. Only a clinical person can determine what is medically necessary. If you feel the providers are padding documentation to get higher levels refer it on to who ever is above them clinically. Explain your concerns and let them review it and make a determination. If they think it is ok, then you are covered. If they agree with you then they need to address this with the providers.

    Good luck,

    Laura, CPC, CPMA, CEMC

Similar Threads

  1. Exam component of MDM
    By tag60 in forum E/M
    Replies: 1
    Last Post: 04-02-2015, 09:43 PM
  2. History of Skin CA MDM
    By SUEV in forum Dermatology
    Replies: 4
    Last Post: 03-10-2015, 09:43 AM
  3. pre op exam & mdm auditing
    By chatelaine in forum Auditing General Discussion
    Replies: 1
    Last Post: 01-09-2015, 11:06 AM
  4. MDM trumps History and Exam ??
    By Orthocoderpgu in forum E/M
    Replies: 1
    Last Post: 11-19-2010, 06:30 AM

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?


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.