# OIG suggestion for choosing E/M level



## gfarrell (Feb 11, 2012)

I have heard the the OIG is strongly suggesting how to choose an E/M level.  We already know that the AMA / CPT state an established patient only needs 2 out of the 3 components to meet the E/M level.  I understand that the OIG is suggesting/weighing more on the MDM component and that they "strongly suggest" that the MDM should be one of the 2 components to declare the E/M level.   I want to bring this info to my provider but I know he will want hard fast documentation and I cannot find it on the OIG website.  Can anyone provide me with the link to a current document from the OIG about this?  Your help is greatly appreciated!


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## mdoyle53 (Feb 15, 2012)

I have not seen anything about this from the OIG.  However, I agree that the MDM should be a driving factor in choosing a code.  This relates back to the reason the patient is there or the 'Nature of the Presenting Problem'.  For an E&M visit, it is legal to use the Hx and Ex but then I would question whether the medical necessity drives the actual code.  Almost every insurance company indicates in the contract that you will only perform medical necessary services to the members - hence that can somewhat be directed to MDM - but not in all circumstances.


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## melzinser (Feb 16, 2012)

*Not just the OIG...*

CMS has previously stated for awhile that documentation alone shouldn't drive the *selection* of an E&M code, only *support* it.

*"Medical necessity of a service is the overarching criterion for payment in addition to the individual requirements of a CPT code."    *(see CMS Claims Processing Manual, section 30.6.1 - Selection of Level of Evaluation and Management Service, Rev. 2373, 12-21-11)  https://www.cms.gov/manuals/downloads/clm104c12.pdf

The OIG position is due to the realistic fear of automatic overcoding with 'point & click' and 'cut & paste' EHR's.


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## dclark7 (Feb 16, 2012)

Anthem Blue Cross of CT updated their documentation guidelines effective 12/1/11.  They now require MDM as one of the two components to determine the E/M level for established patients.  I wouldn't be surprised if others start doing the same thing.


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