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MDM question

  1. #1
    South Salt Lake City
    Default MDM question
    Medical Coding Books
    so I have a question. Im in the middle of doing some internal audits and My question is Only on the MDM portion. when Calculating the MDM you must meet 2 out of 3 of the components. So I just want to make sure I'm understand this correctly so I don't "butt heads" with my Providers for no good reason. I have a example the pt is on Adderal so its a Moderate risk. However that is the only reason for the appointment meaning that there is only 1 point for the DX and No data was reviewed. making it a straight forward MDM. Is that correct?

    Now to the entire portion... if that is correct and based on the audit tool through the AAPC that I have it states that for an est patient the MDM needs to be 1 of the 2 for the 2 out of 3 that must be met to support the Medical necessity. so even if I have a detailed history and a detailed exam based on the MDM I can not put it as a 99214 it would have to be a 99212 for the MDM to be 1 of the 2. Is that correct?

    Any Help on this would be great. I think I have it but want to double check.
    Jody Thompson, CPC

  2. #2
    It should be 99214 as per history and exam. The rule I am taught is drop the lowest and pick the lowest in case of F/U OV. Here if we drop MDM (lowest) and pick lowest (either history or exam), the level would be 99214. I think it would help.

    Girish Dadhich, CPC

  3. #3
    Milwaukee WI
    Default Without seeing the note
    It's hard to give an accurate response without seeing the actual note.. however

    You state you have: 1 problem point; 0 data points; moderate risk. I agree that this equals Straightforward MDM]

    CPT is very clear. For an established patient you chose the level of visit based on two of the three key compenents: History, Exam, MDM. If history and exam are both detailed, I would assign 99214.

    However, CMS has stated that medical necessity is the overarching criterion for selecting the level of service, not the documentation. Some payers have interpreted this to mean that MDM must be one of the two elements when chosing a level of service.

    I am not a clinician. I've read a lot of notes and seen a lot of documentation but I'm not qualified to make a diagnosis or write the documentation of a service myself. If the physician has documented in such a way to meed the CPT requirements for 99214, that's what I code. HOWEVER I absolutely educate (over and over and over again) my physicians about the need to fully document their medical decision making.

    Hope that helps.

    F Tessa Bartels, CPC, CEMC

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