If you have a comprehensive history and physical and a low medical complexity for an established patient. What level would be selected. We were taught by our coding auditor that you drop the lowest level. I thought it was based on medical decision making for texas by trailblazers. I'm very confused
That is definitely a confusing issue. CPT says that the code level is selected base on two out of three key components and generally, one would throw out the lowest level key component when selecting an established code. However, since medical neccessity is really the primary factor in choosing all E/M codes, in practice, MDM is almost always used as one of the two level-determining key components.
In my experience, the coding industry standard is that all established E/M services should be selected by combining the level of MDM documented with either the history or the exam, which ever scores the highest. The code is therefore determined by the Medical Decision Making. The lowest level component - history or exam - is dropped.
There is plenty of documentation in the Medicare literature to establish that a comprehensive history and physical do not support a comprehensive level E/M service independent of Medical Decision Making. Using your Medicare carrier's guidance as the basis for your internal coding policies is a good strategy.
I the history is merely brought forward from a previous encounter then I say you need to drop it, If however the patient's condition made it necessary for the provider to query the patient in depth ( and this is verified in the documentation) then I go ahead and use history and the next highest component in this case exam and code it to a level 5, but the documentation must be there. Not all level 5s have high complexity decision making, but all level 5s must have really good documentation.
Debra A. Mitchell, MSPH, CPC-H