This is a debatable topic and unfortunately I do not have any documentation on this.
In my personal opinion, MDM is the driver of the other two components, exam and history. I feel as if when providers are see a patient they should think backwards - determine the level of MDM first because in most instances in 10-15 seconds, they already know what they are going to do. After the MDM is established, they then may choose to do an exam or the history (if established patient) - whichever is pertinent or medically makes sense. This is their own clinical judgement. This way, you ensure medical necessity of the service.
To better put into prospective for your established patient, if you have a comprehensive history, comprehensive exam, and MDM of straightforward, I'm pretty sure the payers would have a problem if you coded 99215. This is why if you work backwards from the MDM, you can ensure the MDM matches the level of service.
Hope that makes sense!
- ICD-10 Trainings
- Comprehensive Courses
- CPC (Certified Professional Coder)
- COC (Certified Outpatient Coder)
- CIC (Certified Inpatient Coder) NEW!
- CRC (Certified Risk Adjustment Coder) NEW!
- CPB (Certified Professional Biller)
- CPMA (Certified Professional Medical Auditor)
- CDEO (Certified Documentation Expert – Outpatient) NEW!
- CPPM (Certified Physician Practice Manager)
- CPCO (Certified Professional Compliance Officer)
- VIEW ALL CERTIFICATIONS
Coding / Billing Solutions
- Audit / Compliance Solutions
Job Experience / Apprentice Removal
News / Discussion
- Other Resources
- Book Store
- Log In / Join