# Choosing LOS



## akent82 (Jul 3, 2013)

We are having some issues with choosing the appropriate level of service for an established patient when performing an audit. We know that medical necessity is the driving force for any level of service, however we are having trouble when we run into a three way split. Here are two examples:

1. Physician documents a Comprehensive History, Detailed Exam and Straightfoward MDM.
2. Physician documents an EPF History, Detailed Exam and High MDM.

We are having trouble with which level of service would be appropriate and explaining this to our new coders when training on auditing. We have received advice from our current MAC on this, however our MAC is changing in September and we would like some outside opinions on this.

Any help would be appreciated.


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## vhaysom (Jul 3, 2013)

I would code #1 as a 99212. The over arching criterion for a level of service needs to be driven by the Medical decision making. You could explain to the provider that since it meets a level two according to MDM, and the HPI and exam meet the criteria for a level 4 visit, this would be considered an overdocumented level 2 visit.

I would code # 2 as a 99214. It looks like the exam and the MDM together would meet the criteria for a level 4. For an established patient visit you only need to meet 2 out of 3 to come up with the level.

Hope this helps.
Val Haysom CPC, CPMA


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## nyyankees (Jul 5, 2013)

akent82 said:


> We are having some issues with choosing the appropriate level of service for an established patient when performing an audit. We know that medical necessity is the driving force for any level of service, however we are having trouble when we run into a three way split. Here are two examples:
> 
> 1. Physician documents a Comprehensive History, Detailed Exam and Straightfoward MDM.
> 2. Physician documents an EPF History, Detailed Exam and High MDM.
> ...



I would wonder why a Comp History and Detailed exam would be necessary for a straightforward MDM? I would ask the physician was it really necessary?


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## GaPeach77 (Jul 5, 2013)

Running the levels through MD AUDIT I received a 99213 for the first scenario and a 99214 for the second scenario.


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## MikeEnos (Jul 5, 2013)

vhaysom said:


> I would code #1 as a 99212. The over arching criterion for a level of service needs to be driven by the Medical decision making. You could explain to the provider that since it meets a level two according to MDM, and the HPI and exam meet the criteria for a level 4 visit, this would be considered an overdocumented level 2 visit.
> 
> I would code # 2 as a 99214. It looks like the exam and the MDM together would meet the criteria for a level 4. For an established patient visit you only need to meet 2 out of 3 to come up with the level.
> 
> ...



Medical Decision Making IS NOT the "overarching criterion for payment." You're thinking of medical necessity. Those to terms do not mean the same thing, and are not interchangeable.  Be aware that a patient may be following up on a serious illness - heart disease, cancer, severe back pain, etc.  If the patient is stable, and no tests are done, that qualifies as a straightforward case in terms of complexity.  HOWEVER, I would sure want my doctor to perform at least an expanded problem focused exam, and perhaps a detailed history.  That doesn't mean the physician should be limited to coding it as a 99212 if they felt it was medically necessary to perform a detailed history and EPF exam .... just because the problem is stable today, and no tests are needed.  

You need to be very careful if you are taking cases like those and down-coding them to 99212 without regard to the nature of the presenting problem.  You can really find yourself at odds with the physician who may feel he performed a level 3 or even 4 follow-up service, but you are knocking it all the way down to 99212 because the MDM didn't score high enough.

The MDM is not the same as the medical necessity.  It's just a matrix of check-boxes and grids that is our best estimation at reliably scoring the incredible complexity and cognitive labor that goes into a wide range of physician encounters with patients.  It is a pretty good estimation, but it is not a be-all-end-all way to score the level of service.


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## nyyankees (Jul 10, 2013)

MikeEnos said:


> Medical Decision Making IS NOT the "overarching criterion for payment." You're thinking of medical necessity. Those to terms do not mean the same thing, and are not interchangeable.  Be aware that a patient may be following up on a serious illness - heart disease, cancer, severe back pain, etc.  If the patient is stable, and no tests are done, that qualifies as a straightforward case in terms of complexity.  HOWEVER, I would sure want my doctor to perform at least an expanded problem focused exam, and perhaps a detailed history.  That doesn't mean the physician should be limited to coding it as a 99212 if they felt it was medically necessary to perform a detailed history and EPF exam .... just because the problem is stable today, and no tests are needed.
> 
> You need to be very careful if you are taking cases like those and down-coding them to 99212 without regard to the nature of the presenting problem.  You can really find yourself at odds with the physician who may feel he performed a level 3 or even 4 follow-up service, but you are knocking it all the way down to 99212 because the MDM didn't score high enough.
> 
> The MDM is not the same as the medical necessity.  It's just a matrix of check-boxes and grids that is our best estimation at reliably scoring the incredible complexity and cognitive labor that goes into a wide range of physician encounters with patients.  It is a pretty good estimation, but it is not a be-all-end-all way to score the level of service.



I agree but I have a doc that states a follow-up for a hemorrhoids is NEVER a 99214. Are you saying that if you have a Detailed History, Detailed Exam & Straightforward MDM with a serious dx such as cancer or heart disease billing a 99214 is acceptable. But in the same case we have a dx of pharangitis a 99214 would be a stretch? Thanks as it can sometimes be confusing.


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## maddismom (Jul 10, 2013)

I agree with vhaysom.  It is commonly understood and compliantly practiced that MDM MUST be one of the two of three for an established patient.  I guess it depends on your practice or guidelines, but I would encourage anyone to follow that guideline.  Anyone can do a complete History and Exam (they're check boxes, also) to get a higher level, so yes, MDM and medical necessity do relate.  Plus, as an auditor, it takes away the gray areas.  Just my opinion.......


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## dclark7 (Jul 10, 2013)

I would check with the carrier.  You may have to wait until your MAC changes, or if you know who your MAC will be you may be able to contact them now for advise.  

Anthem B/C of CT has made it a policy that one of the 2 elements for an established patient must be MDM the other element can be either History or exam.


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## mhstrauss (Jul 10, 2013)

maddismom said:


> I agree with vhaysom.  It is commonly understood and compliantly practiced that MDM MUST be one of the two of three for an established patient.  I guess it depends on your practice or guidelines, but I would encourage anyone to follow that guideline.  Anyone can do a complete History and Exam (they're check boxes, also) to get a higher level, so yes, MDM and medical necessity do relate.  Plus, as an auditor, it takes away the gray areas.  Just my opinion.......



I respectfully disagree with your statement "MDM MUST be one of the two of three for an established patient".  I know that some MAC's require this; however, mine does not, and neither do AMA/CPT guidelines.  Now, does that mean that any provider can load up on History and Exam components to meet a high LOS for a straightforward problem? Absolutely not.  But as Mike pointed out above, sometimes the work documented in the H & E is necessary for a stable problem that does not meet high-complexity MDM requirements due to no testing, followup, etc, and the provider should not be penalized for this.  If it appears that your providers are consistently doing this, it presents as an excellent education opportunity.

Just my two cents.


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## MnTwins29 (Jul 10, 2013)

Something I want to add to this is while I agree that MDM does NOT have to be one of the two key elements - what was the amount of work done for the exam and, especially with the EHR, how is the history documented?   While I know only the current note should be used, thanks to copy and paste, I have seen some HORRIBLE documentation of the history element.   Social history - free text says patient is married, the documentation brought over in the current note from last visit says patient is single - no explnation for difference.   Last colonoscopy 11/xx/200x, but later in note - "Hx of polyps on last colonscopy 2010".   Hello????  Do they really look at this stuff or just copy, paste and expect us to give them credit for it????


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## RebeccaWoodward* (Jul 10, 2013)

I agree with Mike.  When a thorough history and exam are documented, the presenting problem should be supported by medical necessity if the MDM results a lower complexity.  MDM is the outcome of the visit; it does not negate medical necessity. Now...I know there are some MAC's that may require MDM as on of the factoring components.  My MAC follows traditional CMS guidelines.

I'm not advocating that all scenarios will default to a higher level based on just the history and exam but there are some legitimate reasons for this type of documentation.  

Chapter 12:

*Medical necessity* of a service is the overarching criterion for payment in addition to the individual requirements of a CPT code. It would not be medically necessary or appropriate to bill a higher level of evaluation and management service when a lower level of service is warranted. The volume of documentation should not be the primary influence upon which a specific level of service is billed. *Documentation should support the level of service reported.*

*Palmetto GBA:*


E/M Weekly Tip: Medical Decision Making

The guidelines do not state that Medical Decision Making (MDM) must be one of the key components documented; however please keep in mind MDM will support/steer medical necessity. For example, a provider may document a comprehensive History and Examination; which would meet the requirements for CPT code 99215 (level five office visit); however you must determine if it was medically necessary to document a comprehensive History/Examination (based on the presenting problem(s)). The MDM will (diagnoses/problems and management) help substantiate the level of service.


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## maddismom (Jul 11, 2013)

As I said, just my opinion.  I have worked where MDM was not required as 2 of 3 and it was easy for the provider to get that 99214 when they sent the patient home to gargle.  And, yes, education was given, but if you don't have a policy or guidelines to enforce it, it doesn't do much good (and it's not my current providers).  

I've been at this since 2005 and the policy to require MDM as 2 of 3 is the best I've ever seen.  Obviously every practice needs to decide for themselves what is best for them and if the exceptions negate this.


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## wrightju1 (Jul 11, 2013)

I have to agree with Mike.  Don't confuse Medical Necessity with MDM.  The E/M code reflects the work the provider did. Not the seriousness of the patients condition.  And yes, even in Oncology and Cardiology there are lower level office visits with established patients (thank God!).  As long as the Medical Necessity supports the History and Exam level, then go with those two over the MDM.  Remember, the doctor isn't being paid by the dx.  Even if it turned out to be High Complexity MDM, if the provider didn't do a Comprehensive History and Complete Exam he didn't do the WORK to bill for a higher service level.  Because he didn't provide the higher service level.


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## maddismom (Jul 11, 2013)

"Palmetto GBA:


E/M Weekly Tip: Medical Decision Making

The guidelines do not state that Medical Decision Making (MDM) must be one of the key components documented; however please keep in mind MDM will support/steer medical necessity. For example, a provider may document a comprehensive History and Examination; which would meet the requirements for CPT code 99215 (level five office visit); however you must determine if it was medically necessary to document a comprehensive History/Examination (based on the presenting problem(s)). The MDM will (diagnoses/problems and management) help substantiate the level of service."

Rebecca CPC, CPMA, CEMC


Which was my point exactly.


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## RebeccaWoodward* (Jul 12, 2013)

maddismom said:


> "Palmetto GBA:
> 
> 
> E/M Weekly Tip: Medical Decision Making
> ...




Which is?


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## mhstrauss (Jul 12, 2013)

Juli.W said:


> I have to agree with Mike.  Don't confuse Medical Necessity with MDM.  The E/M code reflects the work the provider did. Not the seriousness of the patients condition.  And yes, even in Oncology and Cardiology there are lower level office visits with established patients (thank God!).  As long as the Medical Necessity supports the History and Exam level, then go with those two over the MDM.  Remember, the doctor isn't being paid by the dx.  Even if it turned out to be High Complexity MDM, if the provider didn't do a Comprehensive History and Complete Exam he didn't do the WORK to bill for a higher service level.  Because he didn't provide the higher service level.



Now I need a "Like" button


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## mitchellde (Jul 12, 2013)

mhstrauss said:


> Now I need a "Like" button



Agree!!  I tell my classes, it is easy for anyone to document a high level of care especially with the templets they use (hate those things), the real question is given the patient's presenting problem and co-morbidities, SHOULD you have performed that level.  As Mike has stated the level of visit should be based on medical necessity.  Many years ago we had a criteria that was used to justify admission to the hospital it was call SI=IS and is still a good rule of thumb.  Severity of Illness must be equal to the intensity of service provided.  It is still what I use when I evaluate the documentation.


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## RebeccaWoodward* (Jul 12, 2013)

mitchellde said:


> Agree!!  I tell my classes, it is easy for anyone to document a high level of care especially with the templets they use (hate those things), the real question is given the patient's presenting problem and co-morbidities, SHOULD you have performed that level.  As Mike has stated the level of visit should be based on medical necessity.  Many years ago we had a criteria that was used to justify admission to the hospital it was call *SI=IS* and is still a good rule of thumb.  *Severity of Illness must be equal to the intensity of service provided.*  It is still what I use when I evaluate the documentation.




Interesting concept...thanks for sharing!


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## Sanjit (Aug 19, 2016)

*MDM being a Driving Factor*

First of all, we all are aware of:
1. Medical Necessity
2. MDM being Driving Factor in deciding E/M
3. CMS/AMA guidelines

But, best answer should be set by our own logical analysis based on above parameters.
1st Question:
Does the Patient's condition warrants and reflects that the physician has made every effort to take care of the Evaluation part which are part of History and Physical Exam to be at a level of Comprehensive Level but there was no medical necessity to perform any part of additional MDM component in that session?

2nd Question:
Does the Physician made any exaggeration of documenting History and Physical Exam where MDM vis-a-vis Medical Necessity doesn't demand such high level of documentation of History and Physical Exam? 

I think answers to both these questions will give clarity to our thought process keeping above all the three parameters at the highest esteem.

Sanjit.


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