AAPC - Back to school
Results 1 to 5 of 5

Thread: High level evaluation and management

  1. #1
    Join Date
    Apr 2007

    Lightbulb High level evaluation and management

    AAPC: Back to School
    My question is if the provider is billing a 99214, but the documentation supports a comprehensive history and examination and moderate decision making would it be appropriate to up code the level of service to a 99215 or would the medical decision making drive the level of evaluation and management service?

  2. #2
    Join Date
    Apr 2007
    Daytona Beach, FL


    You will probably get a lot of other opinions on this issue, however I will tell you that for an established patient you only need to meet 2 of the 3 components to qualify for that level - the guidelines do not specify that one of those components must be the MDM. Therefore, yes you can code a 99215 based on just the History and the Exam. There are times when this is approriate. However, if your provider is consistently doing higher level exams for lower MDMs, I would suggest that you make sure that he is documentating appropriatley to the medical necessity and not to purposely upcode.

    I know others may try and dispute this based on the statement that the MDM is the over-arching decision for a level, yada yada - but I offer this information based on what we were advised by our Medicare carrier, Highmark Medicare Services. We have also had come charts reviewed for CERT that were billed as 99214 and they were actually corrected to 99215 using this criteria and we were paid the additional fees!!

    Hope this helps you in some way!

    Jodi Dibble, CPC

  3. #3
    Join Date
    Apr 2007
    Barren River Kentucky



    I agree with you. To me that is a no brainer.

  4. #4

    Default May be Insurance driven

    Hi all,
    I don't know if this affects all Anthems, but Anthem Maine now requires MDM as 1 of the 2 for established visits as of 02/01/11. Not sure if others may follow...
    Sue Vermette, CPC

  5. #5
    Join Date
    Apr 2007
    Jacksonville, Florida - 90417

    Default High level evaluation and management

    I agree with Jodi with one small clarification. It is not the MDM that is the overarching criterion it is the medical necessity. Per Medicare's Internet Only Manual 100-04, chapter 12, section 30.6.1 (A), "Medical necessity of a service is the overarching criterion for payment in addition to the individual requirements of a CPT code."

    Maryann Palmeter, CPC, CENTC

    Maryann C. Palmeter, CPC, CENTC, CPCO

Similar Threads

  1. Evaluation Management
    By mos2323 in forum Medical Coding General Discussion
    Replies: 0
    Last Post: 06-26-2013, 09:09 PM
  2. Evaluation and Management and Hemacult
    By Griffin in forum E/M
    Replies: 1
    Last Post: 04-20-2012, 09:00 AM
  3. Gi evaluation and management
    By veloso in forum Gastroenterology
    Replies: 3
    Last Post: 09-20-2011, 08:59 AM
  4. evaluation and management
    By thelma in forum Orthopaedics
    Replies: 2
    Last Post: 02-22-2011, 07:55 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.