# Would you bump this up to a 99214 ??



## Orthocoderpgu (Dec 6, 2012)

EPF History
EPF Exam (95 Rules: four systems examined)
Mod MDM (With HIGH risk on Table of Risk chart due to toxic Rx)

Patient is addicted to opioids and is taking a Rx that needs to be watched closely for toxicity and has asthma which is excacerbated. The addiction is stable.

Strickly speaking this would be a 99213 adding up everything. However, had the physician examined just one more body system, it would be a 99214.

With MDM being "The over-arching factor" according to Medicare, I think I would bill out a 99214 because there is MOD MDM and is High on the Table of Risk due to the Rx that must be closely watched for toxicity. If the patient were not on a toxic Rx, I would not even question it, but...

Agree? Disagree? What do you think E/C coders?


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## valgals (Dec 6, 2012)

*I would tend to agree with you*

Your logic is sound. I would also consider time spent. If the doctor took a considerable amount of time (25 minutes) with this patient that would need to be documented as well.


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## TamekoWood (Dec 6, 2012)

*No I wouldn't bump it up*

This is really a straight forward decision making situation.  The patient is addicted and will have to be monitored but the problem was easy to find and until it proved to be a bigger issue with addressing the addiction I think 99213 is fine.  The Doctor didn't go to the extra step needed to bill for a 99214.


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## Karolina (Dec 7, 2012)

*No, 2 out of 3 needed*

You should not bump this up - you must have 2 of 3 of the elements documented. Either history or exam also needs to meet criteria for 99214, otherwise it is a 99213. MDM is the overarching, but not the only, factor. That comes more into play if you have a complete history and a complete exam with a low MDM, then you would adjust downward. 
Regarding time: It not only needs to be documented, the provider must also have spent more than half of the time in counseling the patient about the issues at hand and the note must reflect that accordingly.
Bottom line: only code what you have in writing, don't interpret stuff into the note.


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## cheermom68 (Dec 7, 2012)

I agree with Karolina, without either a detailed history or exam, or the correctly documented time in counseling and coordination of care, you would have to bill the 99213.


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## jlparker0898 (Dec 7, 2012)

I agree with Karolinda as well...Only 2 out of 3 are required for an established pt. Bumping it up to a 99214 because of the MDM would be out of compliance


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## MikeEnos (Dec 7, 2012)

I agree with those who say you should NOT consider this to be a 99214.  

Although it is supposed to be the 'overarching criterion' for payment according to CMS, I take that to mean that if you have a provider who uses an EMR and they consistently document a Comprehensive History and Comprehensive Exam, you should not be billing everything at level 5.  The medical necessity does not support such extensive histories and exams for every patient.

So my rule of thumb; I can use that '_overarching criterion_' statement as justification to suggest a lower level, but I never use it as justification to suggest a higher level if the other key components don't meet or exceed the requirements.  

As-is, I would use this note as a learning experience for your provider.  Show them how just a little better documentation would have justified a higher level.  Or show them how they can document a time statement if greater than 50% of the visit is spent counseling the patient (as sounds like it may have been the case here.)  If the visit lasted 25 minutes and they spent 15 minutes talking about the dangers of this addiction, and how it is exacerbating his asthma, that justifies a level 4 even without extending the history or exam.


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## LLovett (Dec 10, 2012)

*MDM is not the same thing as Medical Necessity*

While I agree you can't bump it based on what you have, I agree had there been either a detailed history or exam it would be a 99214.

The only reason I am weighing in is due to the statement that MDM is the overarching criterion, it is not. Medical Necessity is the overarching criterion. MDM can be manipulated the same way history and exam can to support a higher level. They can order all kinds of tests and records while assessing multiple diagnosis at every visit, doesn't mean it was medically necessary. You can also have 1 established problem that is worsening which only gives you 2 points but if you look at the table of risk, that same problem can fall under high risk. So because your dx points are limited to 2 does that make the rest of the work invalid? 


Ok, getting off my soap box now, just my opinion for what its worth,


Laura, CPC, CPMA, CEMC


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## MikeEnos (Dec 10, 2012)

I agree - MDM is NOT the same as Medical Necessity.  There's a certain amount of subjectivity involved with determining the medical necessity (especially for folks like me who are not at all clinicians) but keeping that distinction in mind is very important.

_Medical necessity_ is the overarching criterion for payment per CMS, not necessarily MDM.


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