Trailblazer and E/M
While Trailblazer is not our MAC, I was curious about this post and searched their site. I found something very interesting in their September 2011 bulletin. In that issue, they publish the results of audits done for office visits and inpatient hospital visits. The bulletin lists one example of an office visit that they cite as being over-coded.
Here is why I thought it was interesting - they list the diagnoses (ear wax which could lead to an infection, along with tinnits and sensory hearing loss) as "low to moderate in severity." Because of this classification and not the "moderate to high severity" this bulletin states is required to meet moderate MDM, they downgraded the visit from 99204 to 99203. Even if one agrees with this assessment (skeptical because I am not reading the entire record), what about the other two parts of MDM, the risk and data? Since the bulletin did not publish the entire note, the reader doesn't KNOW what else was documented.
Therefore, with this information as published, I would conclude, and keep in mind this is the first time I have read a Trailblazer bulletin as this is not our MAC, is that this MAC bases MDM solely on severity, using that as the criteria to determine "medical necessity" And since "medical necessity" is the "overarching criterion" (as we have all heard time and time again), I interpret this as the level of MDM must be used as one of the elements. Maybe using a new patient isn't the best example, but it still made me think, "What are they using?"
If you are interested: http://www.trailblazerhealth.com/Pub...tember2011.pdf
Last edited by MnTwins29; 02-20-2012 at 09:41 AM.
Reason: Added link for bulletin
Lance Smith, MPA, COC, CPMA, CEMC, RHIT, CCS-P, CHC, CHPC
Ellenville, NY Local Chapter