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MDM trumps History and Exam ??

  1. #1
    Location
    Salt Lake North
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    639
    Cool MDM trumps History and Exam ??
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    An auditor recently came to our clinic stating that due to a Medicare Bullitin which states that MDM should be the "Over-Arching Factor" in deciding an E/M level, she basically wants us to set aside History and Exam. If I were to code this way, some of my visits would be "Up-coded" and some "down-coded". I respect this auditor and her experience, but can see problems coding this way. Have any of you had a similar experience and what did you do?

  2. #2
    Location
    North Carolina
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    3,126
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    Quote Originally Posted by qcoder View Post
    An auditor recently came to our clinic stating that due to a Medicare Bullitin which states that MDM should be the "Over-Arching Factor" in deciding an E/M level, she basically wants us to set aside History and Exam. If I were to code this way, some of my visits would be "Up-coded" and some "down-coded". I respect this auditor and her experience, but can see problems coding this way. Have any of you had a similar experience and what did you do?
    While MDM is important, her statement isn't exactly correct. Per CMS...

    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. Documentation should support the level of service reported. The service should be documented during, or as soon as practicable after it is provided in order to maintain an accurate medical record.

    http://www.cms.gov/manuals/downloads/clm104c12.pdf

    30.6.1

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