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Thread: Est Pt-2/3 comp

  1. #1
    Join Date
    Apr 2007

    Default Est Pt-2/3 comp

    AAPC: Back to School
    There is an issue my ofice is having with determing levels with established patients. The requirements per CPT guidlines is you only need 2/3 components to meet a level. Now our question is due to EMR's, comprehensive History and PE is very common. Or comprehensive and Detailed history and PE. Now if you add this to a system such as 3M, it gives you level 5 and level 4. regardless of the MDM. I find it hard to not have to bring MDM into consideration, so I wanted other opinions on how others are basing this. Are you using the MDM to bring it down a level? Thank you in advance!

  2. #2


    My experience has involved an internal office policy of MDM drives the E/M level when 2 out of 3 components are required.

  3. #3

    Default Does MDM affect the level in est outpt when the Hx and PE leads the high level

    I have the same question, when Hx is detailed and PE is detailed, can we arrive the level 99214 eventhough the MDM is straight forward? Does the MDM affect the 99212- 99215 levels when Hx and PE is sufficient, the rule is 2/3.

  4. #4
    Join Date
    Apr 2007
    White Plains, NY

    Default Overdocumentation

    This may be hard for some of you to understand: yes, you only need 2/3; however, the driver of the code is the medical necessity of the visit. So if you have someone who comes in to have for something minor, like a cut cleaned and sutured, or an earache, what is the medical necessity of doing a 9 system exam? The Doc has overdocumented the visit.
    This is going to be an ongoing problem with EMRs. Often the ROS is not actually done, just cut and pasted from a previous vist. Or the exam is "cloned" from an earlier time, or everything is check off as "normal" or "unremarkable."

    Yes, you will probably get paid for the high E/M level for a while, and then the practice will get audited, and the medical necessity of all that overdocumentation will get called in to question.
    Just because you CAN, doesn't make it right, or legal.


    (CFE= Certified Fraud Examiner)

  5. #5
    Join Date
    Apr 2007


    Thank you for your reply, I feel the same way. Some of the coders that I work with justify that the CPT book hasnt changed to say anything about MDM driving the level. But I totally agree and have justified, just because we "can" doesnt mean we "should". Unfortunately it is so easy for doctors to over document with the EMR's. And it is very diffucult to get them to stop.

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