# Medical Necessity vs. MDM



## 1073358 (Dec 14, 2012)

I know the 2 are different. I keep hearing that the over arching component is medical necessity. My question is, how to you "score" it. How do you determine if medical necessity is met? What makes something mecically necessary at a level 3, but not a level 4 for example...??????? 

I have seen where a note will audit per EM guidelines to a level 3 or 4, but have seen it coded lower because medical necessity not met for that level. Based on what???? I am really confused at that.


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## LLovett (Dec 14, 2012)

Unless your carrier requires MDM to be one of the components used in a 2 of 3 code, you should be dropping the lowested level component and selecting the appropriate code based on the remaining 2 components. If you have a provider that is always documenting a comp history and exam, this is an issue that needs to be dealt with globally not on a note by note basis.

Most coders/auditors are not clinical, myself included. I'm not stupid either, I can make a decision to question a provider or refer something on for someone clinical to review it. For me to drop an E/M based on a judgement I am not qualified to make is completely out of scope for my job. As stated I can hold the claim and ask for clarification or a peer to peer review but I cannot arbitrarily decide what is or is not medically necessary.


Laura, CPC, CPMA, CEMC


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## ollielooya (Dec 14, 2012)

Laura, great response!  This is worth memorizing ;-)


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## MikeEnos (Dec 16, 2012)

Exactly, Medical Necessity is NOT the same as MDM, but unfortunately it's not something you and I can 'score' since we are not doctors.  I can use my best judgement, but if there's a question in my mind I usually defer to the doctor's clinical judgement.  There are often combinations of presenting problems and medical history that require the physician to consider more serious implications... that may not always be clear to me.  Similarly, there is no comprehensive list of diseases that are considered to be Low Risk vs Moderate Risk vs High Risk.  There is no comprehensive list of 'Minor or Self-Limited Problems' vs 'New Problem with no additional Workup needed.'  I also score those on a case-by-case basis and bring any concerns to the doctor.

Obviously with today's EMRs it is possible for a provider to always document a Comprehensive History and Comprehensive exam, but the question is - what is the highest level of medically necessary history and exam that were documented?  If they are always documenting Comprehensive Histories and Exams, and always selecting level 5 follow-ups because of that, I would be concerned and would recommend meeting with them immediately to discuss that.  But you also shouldn't arbitrarily down-code their visits just because you doubt the medical necessity.  My advice would be to defer to their clinical judgement, but to talk to them about the medical necessity.  If you regularly find yourself doubting it, talk to them about making it more clear in the Assessment and Plan what sort of decision making went through their head.  What sorts of comorbidities or more serious underlying illnesses did they consider?  Talking with them is best for everyone involved - discussion leads to improved communication among your team and enhanced knowledge on all sides.  If you just start making judgement calls and down-coding them, it could result in some resentment, and I would strongly advise you to stay away from any situation in which you are arguing with a doctor about the medical necessity of the history or exam.  You may find yourself swimming in unfamiliar waters that you cannot tread.  Instead just encourage them to make it clear in the Assessment and Plan what their thought process was.


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## 1073358 (Dec 18, 2012)

*MN*

Great replies!! My argument to anyone asking is that I am a CPC not an MD.. how would a CPC EVER know med necessity unless they are also an MD? I would never ever approach an MD and tell him something wasnt medically necessary from my perspective, because really, what do i know!

My struggle comes in because there is such focus on this right now (or atleast in our organization) and I am working with residents. I am trying to teach them all they need to know to succeed in the "real world".. and i really struggle with how to teach them the differences between the levels. I can tell them what documentation is required for each visit, but i dont know how to teach them to "feel" what each service is worth. And of course being residents, they over document everything.. so that throws another loop into it.


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## npricercm (Oct 16, 2013)

1073358 said:


> Great replies!! My argument to anyone asking is that I am a CPC not an MD.. how would a CPC EVER know med necessity unless they are also an MD? I would never ever approach an MD and tell him something wasnt medically necessary from my perspective, because really, what do i know!
> 
> My struggle comes in because there is such focus on this right now (or atleast in our organization) and I am working with residents. I am trying to teach them all they need to know to succeed in the "real world".. and i really struggle with how to teach them the differences between the levels. I can tell them what documentation is required for each visit, but i dont know how to teach them to "feel" what each service is worth. And of course being residents, they over document everything.. so that throws another loop into it.



Does this issue ever go away MDM should not be the be all and end all of coding an E/M visit.  Every audit tool I look at states take the 2 highest components; they do not state use MDM and then drop the lowest of HPI and the exam.  No one can produce anything in writing that states to use MDM and drop the lower of the other two components.  Does anyone have that somewhere?


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## dclark7 (Oct 17, 2013)

npricercm said:


> No one can produce anything in writing that states to use MDM and drop the lower of the other two components. Does anyone have that somewhere?


 

Anthem Blue Cross/Shield of CT, has specifically stated in their Reimbursement Policy for E/M coding that MDM is one of the two elements considered when choosing a level.  This has been their policy since 1/2011.  I don't know of any other insurance company that has specifically stated this.


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