# Medical Decision Making Component Importance



## heatherwinters (Feb 11, 2008)

I would like some feeback regarding the importance of the level of medical decision making when determining an EM.  Only two of the three components, history, exam, and Medical Decision Making are needed to determine an EM level.  Should the Medical Decision Making component always be one of the two?


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## storturica (Feb 11, 2008)

*E&M*

HI,
 If you read through the E&M guidelines you will find that if the service is office, new patient; hospital observation services; initial hospital care; office consultations; initial inpatient consultations; emergency department services; initial nursing facility care; domiciliary care, new patient; or home, new patient then you must have ALL of the key components. If it is office, established patient; subsequent hospital care; subsequent nursing facility care; domiciliary care, established patient; and home, established patient then  you only need two out of three.


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## mmelcam (Feb 11, 2008)

I haven't read anywhere that medical decision making has to be one of the two components. If you are coding an established patient office visit and you have a detailed history, a detailed exam, and a low complexity of medical decision making, I would still code this as 99214 because two of the 3 components within that column are met and that is all that you need for established patient visits.


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## rthames052006 (Feb 11, 2008)

heatherwinters said:


> I would like some feeback regarding the importance of the level of medical decision making when determining an EM.  Only two of the three components, history, exam, and Medical Decision Making are needed to determine an EM level.  Should the Medical Decision Making component always be one of the two?



I think you may be talking about Medical Necessity and not medical decision making. 

let us know.

Roxanne Thames, CPC


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## heatherwinters (Feb 12, 2008)

*Medical Decision Making*

I am referring to the complexity of medical decision  as a component of the Level of Service (comprised of Number of Diagnoses or treatment options, amount and or complexity of data reviewed, and Risk of Complications and/or morbidity or mortality).  Thanks


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## rthames052006 (Feb 12, 2008)

heatherwinters said:


> I would like some feeback regarding the importance of the level of medical decision making when determining an EM.  Only two of the three components, history, exam, and Medical Decision Making are needed to determine an EM level.  Should the Medical Decision Making component always be one of the two?



No, MDM doesn't have to be one of the two components ( dealing with established, not new) it can be any two of the three.

Roxanne Thames, CPC


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## heatherwinters (Feb 13, 2008)

Thank you for your help


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## heatherwinters (Feb 13, 2008)

*Feb 2008 Coding Edge Magazine*

According to a recent article in Coding Edge Magazine,  The Ten Commandments of EM Coding" 

Medical Decision Making (MDM) Must Match Service Level MDM is the overriding determinant of the level of service, and a billed service level should never exceed the MDM reflected in the documentation. Be familiar with your Medicare intermediary's criteria for evaluation of MDM and apply those criteria stringently to your provider's records. If you meet Medicare criteria onsistently, then the records should easily fulfill criteria for private insurers.


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## gailmc (Feb 15, 2008)

We have a Compliance Policy that states for established patients, Medical Decision Making must be one of the 2 of 3 elements when determing a LOS.  We did this to ensure medical necessity was being met.


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## Lisa Bledsoe (Feb 15, 2008)

I used to think that it didn't matter which two of the three components were met...but have come to realize that the MDM *supports* the medical necessity of the rest of the visit and should therefore be the driving factor.


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## grahamki (Feb 22, 2008)

Our compliance department requires that MDM be 2 of the 3 componets for an established patient, where as it is 3 of 3 for a new patient.  This is to unsure that MDM is being met. But you can always refer to your Medicare provider for their requirements. As a rule of thumb that I use when I am abstacting a chart I refer to the MDM to get an idea of where the code might fall.  Hope this helps!


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