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MDM level - Can anyone point me to CMS guidelines

  1. #1
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    Overland Park, KS
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    Default MDM level - Can anyone point me to CMS guidelines
    Medical Coding Books
    Can anyone point me to CMS guidelines that state you can't bill higher than the MDM level? For example:

    History-EPF
    Exam-Detailed
    MDM-SF

    You have to go with the MDM for the level.

    Or

    History-Detailed
    Exam-EPF
    MDM-High

    You would go with the exam for the level

    Is this correct and where in the CMS guidelines does it state this? Another auditor told me this and I want to confirm this. Thanks.
    Dawson Ballard, Jr., CPC, CEMC, CPMA, CCS-P, CPC-P, CRHC, AAPC Fellow
    Coder

  2. #2
    Default
    I wish I could give you a specific black and white printed answer, but that would make life to simple. What I do know is that Dr. Deborah Patterson, the medical director for my MCR carrier (Trailblazer) stated that medical necessity is always the driving factor. Yes, I know that coding rules say on subsequent visits you can use 2 of 3 to determine your level, but she emphasized that you need 2 of 3 and one of the three has to be MDM. If you don't stick with MDM, then you could document a really good history and exam for a "cold" and call it a high level visit. You didn't specify what type of visit, if it is an initial you must meet all three criteria to bill a level, the code is then based on whichever element is the lowest.

  3. #3
    Location
    Overland Park, KS
    Posts
    1,166
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    Thanks so much!
    Dawson Ballard, Jr., CPC, CEMC, CPMA, CCS-P, CPC-P, CRHC, AAPC Fellow
    Coder

  4. Default
    "but she emphasized that you need 2 of 3 and one of the three has to be MDM." It would be great if you can share the documented evidence for this.
    Thanks,
    Jagadish, CCS-P, CPC

  5. #5
    Location
    Overland Park, KS
    Posts
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    Default
    Let me try to rephrase my question here:

    If it is a new patient, per the guidelines all three levels must meet. If they don't meet, then you go with the lowest level. I understand this. What if it is an established patient? If you can't bill higher than your MDM level; then if you have an EPF history, a detailed exam, and MDM is high; you bill based on the exam level. Correct?

    Or

    For an established patient, the history level is detailed, the exam is detailed, and MDM is SF; then you bill based on the MDM level because it is the lowest. Correct?
    Dawson Ballard, Jr., CPC, CEMC, CPMA, CCS-P, CPC-P, CRHC, AAPC Fellow
    Coder

  6. #6
    Location
    Greeley, Colorado
    Posts
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    For the established patient you must meet or exceed 2 of 3 key components - one being MDM...so in your first established patient example, the level of service would be 99214 (detailed exam and high MDM). In your second example, I would code as 99212 because of the MDM. The way I look at it, the MDM supports the medical necessity of the exam. Hope that helps...just my opinion in a highly debated area.

  7. #7
    Location
    Overland Park, KS
    Posts
    1,166
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    Thanks so much. I appreciate your opinion.
    Dawson Ballard, Jr., CPC, CEMC, CPMA, CCS-P, CPC-P, CRHC, AAPC Fellow
    Coder

  8. Default
    I agree that MDM always drives the final level of service. But, anybody, please help me if there is any documented evidence from CMS or any of its carriers that; for an established patient when we are considering only 2/3; we have to consider MDM as one of the salient feature. Because lot of established patients' charges we are coding will have minimal MDM or sometimes completely MDM will be missing; and we are assigning the level based on History and PE.
    Thanks,
    Jagadish, CCS-P, CPC

  9. #9
    Location
    north seattle wa
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    103
    Default CMS documentation
    Pub 100-04
    Medicare Claims Manual, Chapter 12 30.6.1 Selection of level of Evaluation and Management Service

    A. (second Paragraph) "Medical necessity of a service is the overarching criterion for payment in addition to the individual requirments of a CPT code. It would not be medically necessary or appropriate to bill a higher level of evaluation and management service whena lower level of service is warranted. THe volume of the documentation should not be the primary infulence upon which a specific level of service is billed. Documentation should suppoert 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."

    Hope this helps.

  10. Default
    Thanks Wendy!
    Thanks,
    Jagadish, CCS-P, CPC

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