# Determining Level of Service



## lillianivy

Need Clarification... Even tho the History and Exam meet a comprehensive level, but the MDM is low complexity can you still bill for a 99215.  I know you only need 2 of the 3 to meet criteria but for a follow up visit the physician fills out all the history and does a full exam but orders no test or reviews no test and just puts the same DX from last visit and states to RTC in 3 months.  Just have a hard time giving that a high level.  Any advise would be great.  EMR is making it so easy to have a comprehensive History and Exam every time.  Help!!!!

Thank you,

Lydia


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## LilMissCoder

Even though the guidelines state that you only need two out of three for an established patient, it also states that the visit must meet medical necessity to justify the level of service.  When put into that context, a visit with very low MDM would not qualify for a 99215 based on medical necessity.  

I hope that helps.


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## la_0922

This is a tricky one since all elements are met on the HPI and Exam....however, most auditors and Medicare Contactors say that the MDM is deciding factor in what a level should be. Especially since most EMR's require documentation of that caliber, now more than ever, they rely on the MDM. 
Unfortunately it looks like it should be a low level visit. If you would like futher clarification visit your Medicare Contractor website and under the E&M section you should find some helpful links. 

HTH 
Louise CPC


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## lillianivy

Thank you.  That helps so much. So would it be safe to always assume that the 2 of the 3 criteria to be met must be the MDM and either the History or Exam?

Lydia


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## la_0922

I always use the MDM to be safe. 

Louise CPC


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## mhstrauss

Please read through this thread that is currently going on; OP has similar question, and there are some very good points made.

https://www.aapc.com/memberarea/forums//showthread.php?t=94722


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## la_0922

While ther are some very good points made in the link above, I tend to agree with MDM and Medical necessity going hand in hand. If a provider documents a comprehensive history, comprehensive exam, but states, Hypertension Stable, no complaints no med changes that would not justify a level 4 visit.  although your documentation (2 of 3) meets, the medical necessity does not, and that is shown per the MDM. '

Louise CPC


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## wrightju1

Exam and MDM are the best 2 out of 3.  However, even in and Established Patient, if this is a new problem and the History and Exam pertain directly to the Chief Complaint you could be safe using them.  Especially in the case of some pregnant patients.  Even if it turns out to be nothing, it could easily have been a serious problem.  The E/M code is a reflection of the work that the provider did, not the seriousness of the patients condition.  As long as the work can be justified, and is well documented, the provider should be paid for it.


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## kgoldman CPC COC

*Mdm*

I'm going with the over arching criteria of medical decision making!


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## lthomas@grhs.net

Hello - I guess we need clarification on  -  what is the difference between medical decision making and medical necessity?


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## CBaer

*Mdm*

Medical Necessity

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. 
The service should be documented during, or as soon as practicable after it is provided in order to maintain an accurate medical record.


One must take another look at the documentation when MDM is not one of the two supporting key components to ensure that all that was documented within the history and exam were medically necessary based on the nature of the presenting problem (a contributing factor).  That there wasn't any over documenting going on.

A provider (not saying they would) could check all the boxes with the EMR for sinusitis, however the MDM come up low.  I would have to question why they did a ROS/exam on musculoskeletal, GI, GU, psy, neuro and skin. 

If you take a look at the CPT Code definition for 99213 it states the presenting problem is usually of a low to moderate severity.  Where 99215 states High severity.  Therefore based on the nature of the presenting problem of sinusitis 99215 would not be appropriate.

In a perfect world MDM would be one of the supporting key component, and yes some MAC indicate it should be one.  However, I would appeal any claim to any MAC where MDM wasn't one and the other two key components  supporting the level of service billed if the history and exam was all medical necessity.    

I hope this helps.

Cheryl


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## elleyl

*medical necessity vs medical decision making*

Another way to look at medical necessity vs medical decision making is:

The medical necessity for performing the key components of history and exam are determined by the nature of the presenting problem, the patient's own personal history and the clinical judgment of the provider. The medical decision making, that is the diagnostics ordered, the assessment and the plan are formulated as a result of the nature of the presenting problem, the patient's past medical history, and the history and exam performed at that visit.  Medical decision-making is the outcome of the visit and is not a substitute for medical necessity. If CMS had wanted medical decision making to be that substitute then the Medicare Claims Processing Manual would read, “medical decision-making is the overarching criterion in selecting an E/M service” instead of medical necessity.  If CMS had wanted medical decision making to be a substitute for medical necessity than either medical decision-making would be required in determining the code or all codes would require all three components.
Physicians do need to use their electronic health records in a way that more clearly documents what happened at the visit. In most cases that means document what would have been dictated.


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## Rita Bartholomew

*MDM vs medical necessity*

Medical decision making reflects the cognitive effort by the provider -- in other words, what was thought and done.  Medical necessity asks the question "did you NEED to do it?" based on the presenting problem.  Related, but not the same.  And, according to CMS, the overarching criterion for E/M level choice is medical necessity, not MDM.


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## elleyl

Very well stated and to the point!


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## npricercm

elleyl said:


> Another way to look at medical necessity vs medical decision making is:
> 
> The medical necessity for performing the key components of history and exam are determined by the nature of the presenting problem, the patient's own personal history and the clinical judgment of the provider. The medical decision making, that is the diagnostics ordered, the assessment and the plan are formulated as a result of the nature of the presenting problem, the patient's past medical history, and the history and exam performed at that visit.  Medical decision-making is the outcome of the visit and is not a substitute for medical necessity. If CMS had wanted medical decision making to be that substitute then the Medicare Claims Processing Manual would read, “medical decision-making is the overarching criterion in selecting an E/M service” instead of medical necessity.  If CMS had wanted medical decision making to be a substitute for medical necessity than either medical decision-making would be required in determining the code or all codes would require all three components.
> Physicians do need to use their electronic health records in a way that more clearly documents what happened at the visit. In most cases that means document what would have been dictated.



We had the same debate in our office.  There is a formal policy by one of the larger institutions that states MDM has to be one of the components of an established pt visit. 

These issues sound like education or compliance issues; not coding issues.

I agree. There is a difference between medical decision making and medical necessity.  The manual reads that the overarching criteria is medical necessity and not medical decision making.  

Medical necessity is peer to peer, unless you are a clinician, you can't substitute your experience for a clinician's.

Many people equate medical decision making as being documentation of the medical necessity for the visit.  That simply is not true.


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