# Selection of E/M



## HBULLOCK (Jul 21, 2010)

I was under the impression that when selecting your e/m code that MDM had to be one of the 2 criteria met when 2 out of 3 needed.(99212-99215) Am i wrong?  Can it be the HPI and PE? thanks


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## CC5657 (Jul 21, 2010)

When selecting your e/m level on an established patient, you do not need the MDM. If the HPI & Exam will give the provider a higher level e/m, you do not need to base the e/m on MDM (per our carrier). It might all depend on your carrier.


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## Orthocoderpgu (Jul 21, 2010)

*MDM Drives Medical Necessity*

In an Established Patient visit, I think that MDM should be one of the two. The reason for this is that MDM drives "Medical Necessity". If a young patient comes with with a cheif complaint of an earache, are you going to do a Comp History and a Comp Exam? No. That would be over-kill. How could you defend doing this in light of Medical Necessity? Was it necessary to review all of those systems? No. Your overall code selected should not be higher than MDM as a general rule. If it is, you need to be able to defend yourself in an audit stating why all the systems were reviewed.


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## HBULLOCK (Jul 21, 2010)

*Mdm*

Hey qcoder....thanks for your response.  Thats exactly what i thought but there seems to be a difference of opinion among many coders.  If you only go by hpi and pe your codes could get quite high even though it really wasn't necc to check as many os/ba as listed in documentation. I think i'm going to stick with the way i have been handling it.  Thanks for the input!  :d


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## Orthocoderpgu (Jul 21, 2010)

To be honest, it's fairly easy to get Moderate Medical Decision Making (Two stable diseases, Rx drug management) which opens you to everything except a level 5 visit. And your not going to do too many of those anyway.


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## carrnr1 (Sep 28, 2010)

*Medical Decision Making*

It seems medical decision making is the breaking point with many unanswered questions.  Our facility requires that one of the two must meet in medical decision making.  I also get a little confused on why putting a patient on a prescription alone should justify a level four when there is a huge difference on drug management of an antibiotic vs. pain medication, or for a chronic condition with other modifying factors.  I also get confused on what constitutes  acute illness "with systemic symptoms".  This is such a gray area to train providers on and it is a 50/50 split depending on what state you are from, or who the information comes from.  Some providers believe just because they write a script they can bill a four, but I don't feel comfortable with that.  IS there any easy way to decifer this issue?


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## pnwcoder (Oct 13, 2010)

Carrnr1- I totally agree with you on the drug management issue. I code for clinics owned by a regional hospital and someone was hired (a Dr turned coder turned consultant) to instruct us that drug management could make any new problem a 99214. It doesn't matter if it's an antibiotic ointment for a rash or nitro for chest pain. Now most of our Family Practice, Internal med docs have 90% 99214. I think it's crazy and to be honest, after 6 years of coding, I'm having second thoughts as to whether I want to continue in this field.


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## jdibble (Oct 14, 2010)

Writing an RX gives you a* RISK *of Moderate.  This does not gaurantee that this will give you a MDM of Moderate Complex or a guarantee of a level four visit.  You must also take into consideration the other 2 compontents of MDM.  If you are managing at least 3 established problems that are stable, or seeing the patient for a new problem with no additional work-up, then yes, your MDM would be Moderate, or if they are ordering and personally reviewing tests or records, that could also make your MDM moderate, but just saying that if the physician writes an RX makes it automatically a 99214 is not correct. 

As far as the management of an RX, any prescription carries with it a risk, whether it is an antibiotic, skin cream or pain medicine.  The patient has a chance of having a bad reaction to any drug, or if it does not work as planned, the physician incurs the extra work of correcting the RX.  At our facility, if the patient does not get better on the RX given, the patient can call or may have to come back in for a new RX and that visit is not billed, so there is more work involved for the physician when he writes an RX.  So, I feel that writing an RX is correct to be considered Moderate risk and to help in obtaining a higher E/M level.

Also, even though the MDM is supposed to be the driving factor in your level, the *guidlines* say 2 of the 3 must meet or exceed and it does not state that one of those components must be MDM.  So in answer to Helen's question, technically, yes it could be HPI and Exam.  I would however question a level 5 for an ear ache, but I could see a level 4 under the correct circumstances.


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## ohn0disaster (Oct 14, 2010)

qcoder said:


> In an Established Patient visit, I think that MDM should be one of the two. The reason for this is that MDM drives "Medical Necessity". If a young patient comes with with a cheif complaint of an earache, are you going to do a Comp History and a Comp Exam? No. That would be over-kill. How could you defend doing this in light of Medical Necessity? Was it necessary to review all of those systems? No. Your overall code selected should not be higher than MDM as a general rule. If it is, you need to be able to defend yourself in an audit stating why all the systems were reviewed.



I completely agree, qcoder. 
E/M has got to be my least favorite part of being a coder. It's so very subjective. Honestly, the first thing I take into account when selecting an E/M code is MDM. I find it easier to make a code selection by working backwards.


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## ajfinn0216 (Oct 15, 2010)

jdibble said:


> Writing an RX gives you a* RISK *of Moderate.  This does not gaurantee that this will give you a MDM of Moderate Complex or a guarantee of a level four visit.  You must also take into consideration the other 2 compontents of MDM.  If you are managing at least 3 established problems that are stable, or seeing the patient for a new problem with no additional work-up, then yes, your MDM would be Moderate, or if they are ordering and personally reviewing tests or records, that could also make your MDM moderate, but just saying that if the physician writes an RX makes it automatically a 99214 is not correct.
> 
> As far as the management of an RX, any prescription carries with it a risk, whether it is an antibiotic, skin cream or pain medicine.  The patient has a chance of having a bad reaction to any drug, or if it does not work as planned, the physician incurs the extra work of correcting the RX.  At our facility, if the patient does not get better on the RX given, the patient can call or may have to come back in for a new RX and that visit is not billed, so there is more work involved for the physician when he writes an RX.  So, I feel that writing an RX is correct to be considered Moderate risk and to help in obtaining a higher E/M level.
> 
> Also, even though the MDM is supposed to be the driving factor in your level, the *guidlines* say 2 of the 3 must meet or exceed and it does not state that one of those components must be MDM.  So in answer to Helen's question, technically, yes it could be HPI and Exam.  I would however question a level 5 for an ear ache, but I could see a level 4 under the correct circumstances.





Well said Jodi!  I wholeheartedly agree.  Until I see in writing that CMS or my state carrier is requiring MDM to be one of the 2 components for subsequent visits I will not impose that requirement when auditing.  That is not to say that I wouldn't question high level documentation/coding for a relatively "minor" problem.


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## pnwcoder (Oct 15, 2010)

I understand the argument it's just as a patient I think it stinks. I've taken my children in for ear infections just to get the amoxicillan (sp) that they'd taken many times over the years and if I would have been charge $182 for the visit I would have choked. All you need HPI "Her right ear has been hurting 2 days and we've put heat on it but no help. No fever. ROS "No rash, no cough. PMH: Gets 2-3 ear infections a year" New problem + RX=99214 What's not fair is the providers that give antibiotic for EVERY ear pain, sore throat or bug bite or pain meds for every back ache get a 99214 and then other providers that recommend over the counter or heat/ice get a 99213. The providers have picked up on this so guess what? Scripts are written 99% of the time. As for chronics...we've been told Vit D def and obesity can be counted as chronic so basically every person could in reality have 3 chronic dx's. I'm healthy but I have HTN but I'm also overweight and since I live in Oregon I have vit D deff (as do 75% of us in OR) Dr mentions all these and gives HTN med and 99214. I get it... I just don't like it.


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## Bobby A (Oct 16, 2010)

*E/M*

OK correct me if wrong...2nd guessing myself....E/M's include seven components, six of which determine the level of E/M.  The six are hx, exam, mdm, nature of presenting problem, counseling, coordination of care and nature of presenting problem...


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## jdibble (Oct 19, 2010)

Bobby A said:


> OK correct me if wrong...2nd guessing myself....E/M's include seven components, six of which determine the level of E/M.  The six are hx, exam, mdm, nature of presenting problem, counseling, coordination of care and nature of presenting problem...



There are 7 components, yes, but the History, Exam and MDM are the Required Key Elements for code selection.  The others are considered contributory factors and are not needed for you code the level. Counseling can be used if you intend to bill your level based on time - the doctor must document the time he spent counseling the patient and this time must be at least 50% of usual time for the level chosen. The doc must also document the content and support for this counseling.

Hope this helps.


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## jdibble (Oct 19, 2010)

pnwcoder said:


> I understand the argument it's just as a patient I think it stinks. I've taken my children in for ear infections just to get the amoxicillan (sp) that they'd taken many times over the years and if I would have been charge $182 for the visit I would have choked. All you need HPI "Her right ear has been hurting 2 days and we've put heat on it but no help. No fever. ROS "No rash, no cough. PMH: Gets 2-3 ear infections a year" New problem + RX=99214 What's not fair is the providers that give antibiotic for EVERY ear pain, sore throat or bug bite or pain meds for every back ache get a 99214 and then other providers that recommend over the counter or heat/ice get a 99213. The providers have picked up on this so guess what? Scripts are written 99% of the time. As for chronics...we've been told Vit D def and obesity can be counted as chronic so basically every person could in reality have 3 chronic dx's. I'm healthy but I have HTN but I'm also overweight and since I live in Oregon I have vit D deff (as do 75% of us in OR) Dr mentions all these and gives HTN med and 99214. I get it... I just don't like it.



This is a mixed issue - as a patient you feel ripped off, but as a coder, you know it is correct.  I know some doctors understand that giving the RX and such will raise the level, but also in defense of the doctors, I work at an Urgent Care and most of our patients are upset and sometimes quite verbally abusive if the don't get an RX or something for bug bites, simple soar throats, back ache, etc.  They feel they are paying alot of money and if they don't get an antibiotic, whether right or wrong, they are not getting their money's worth.  So, some of our doctors appease the patients with an RX, however we have one doctor who will not give out RX's unless clinically needed - and boy you should hear the names he gets called by these patients!  And the fuss they make at check out when they have to pay "for nothing".  I guess it depends on what side of the fence you are on!!


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## mizzmaryb (Dec 17, 2010)

*additional work up*

Hi folks, i love seeing all the opinions going around about leveling out an E/M.  doesn't it make coding fun? hehe 

anyways...i had a question regarding "additional workup"
what does this actually mean? like what is considered additional workup? dont the points in amt & complexity data include this workup?

thanks~ any feedback would be awesome!


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## sauls (Dec 17, 2010)

when you are auditing, the HPI , ROS and the physical exam must be directly related to the presenting problem, if they are not, you cannot count them as part of the EM coding selection. This rule is an upcoding prevention.


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## jdibble (Dec 21, 2010)

mizzmaryb said:


> Hi folks, i love seeing all the opinions going around about leveling out an E/M.  doesn't it make coding fun? hehe
> 
> anyways...i had a question regarding "additional workup"
> what does this actually mean? like what is considered additional workup? dont the points in amt & complexity data include this workup?
> ...



Hi Mizzmaryb - additional workup means that the doctor is sending the patient for further tests, etc. that will be done elsewhere (i.e. CAT scans, MRI's) and his decision maybe pending these results.  If he does the testing at the same time of the visit (i.e. rapid streps, unrine dips), this does not qualify for additional workup.


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## mizzmaryb (Dec 22, 2010)

thanks jdibble!


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