# When to override code based on MDM



## kmaher

Hello, 

I'm a CPC whose moved up in duties and am now auditing/educating for the company I work for.  I'm not certified as an auditor just yet and so I struggle daily on when is it okay to override the code based on MDM.

My scenerio would be this...  It's an established patient the physician meets a level 99214 based on the HPI, ROS, PFSH and EXAM, but the MDM only meets a level 99213.   Do you keep the level 99214 based on the rule that they only need to meet 2 out of the 3 area's for an established patient, or do you scale it back to a 99213 based on the fact that their MDM doesn't support billing of a 99214.   Any help with this one would be greatly appreciated.  

I currently use the Intelicode product to conduct my audits if that helps.


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## espressoguy

Our hospital's policy is that MDM must be one of the two elements required for an established patient's E/M. Therefore we would always recode a 99214 as 99213 if the MDM was Low, even if the History & Exam were Detailed or higher.


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## kmaher

Can I ask who set forth this policy and how did they come up with this criteria?   I want to make sure I have all my bases covered when I present something like this to my boss.  This is a new position with in our company and I'm the first person to make a go of it.  Thanks for your help.


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## mdoyle53

I would ask - why there is a level 4 hx.  Was it necessary or was it done to obtain the higher coding.

Insurance carriers are looking at medical necessity and unless it was required to treat the patient then I would move the code back to a 99213.

All contracts indicate you will only provide medically necessary services - look at the hx carefully and determine if the steps were necessary!  It is an established patient and hence why did the provider have to document so much?

Mike


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## Pam Brooks

Since Medical necessity (not to be confused with MDM) is the overarching criteria for code selection, there may be times when MDM should not be the key component that drives the code.  For example:  a patient follows up 6 months following chemotherapy for breast cancer.  The provider does an appropriate detailed history, and a detailed examination, but the MDM is straightforward.....Breast cancer, stable.  If you coded this based entirely on MDM, you'd come up with a 99212.  In this case, if there is medical necessity for a detailed history and exam to come to the conclusion of the diagnosis, then a 212 might not be appropriate, since this case isn't of the same caliber as a straightforward resolving ear infection in a 6-year-old.  E&M coding is not always black and white.  What must also be considered is the nature of the presenting problem.  In this case, I'd probably split the difference between a 99212 (per MDM) and a 99214 (per HPI/ROS amd exam).


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## dclark7

You can also check with your insurance carriers.  For instance Anthem Blue Cross of CT has stated in it's policies that MDM is one of the two criteria used to determine E/M levels for established patients.  Either History or exam can be counted for the other.  I don't know if any other insurance companies have done this, but you should verify what their guidelines are.


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## Pam Brooks

Below are the guidelines for NHIC (Northern New England). Although NHIC says that "Physician MDM is critical to determine the overall level of care provided during a patient encounter", I don't necessarily interpret this to mean that MDM must always be one of the two key components, in fact, I don't see that specific language anywhere in the documentation guidelines. I believe that what NHIC is saying is that MDM must always be clearly documented...the presenting problem, status, treatment, and physician's overall thought process, and that by understanding the nature of the presenting problem and the elements of MDM, you can ascertain the necessity of the other key components as relatated to that problem. That concept is what makes MDM critical, and a good place to start, but it may not be the overarching criteria....medical necessity is. I think a lot of coders get caught up in counting all of the bullets, and although that's a part of it, it doesn't always result in the appropriate level of service if the bullets aren't medically necessary. E&M auditing isn't an exact science, but it's interesting once you understand the concept. 

*Medical Decision Making *
[FONT=Book Antiqua,Book Antiqua][FONT=Book Antiqua,Book Antiqua]_Medical decision making (MDM) is considered the thought process of the physician. MDM refers to the complexity of establishing a diagnosis and selecting a management and treatment option as measured by the following: _[/FONT]
[FONT=Book Antiqua,Book Antiqua]_The number of possible _[/FONT][/FONT]*[FONT=Book Antiqua,Book Antiqua][FONT=Book Antiqua,Book Antiqua]diagnoses [/FONT][/FONT]*[FONT=Book Antiqua,Book Antiqua][FONT=Book Antiqua,Book Antiqua]_and/or the number of management options that must be considered. _[/FONT]
[FONT=Book Antiqua,Book Antiqua]_The amount and/or complexity of _[/FONT][/FONT]*[FONT=Book Antiqua,Book Antiqua][FONT=Book Antiqua,Book Antiqua]data - [/FONT][/FONT]*[FONT=Book Antiqua,Book Antiqua][FONT=Book Antiqua,Book Antiqua]_medical records, diagnostic tests, and/or other information that must be obtained, reviewed and analyzed. _[/FONT]
[FONT=Book Antiqua,Book Antiqua]_The _[/FONT][/FONT]*[FONT=Book Antiqua,Book Antiqua][FONT=Book Antiqua,Book Antiqua]risk [/FONT][/FONT]*[FONT=Book Antiqua,Book Antiqua][FONT=Book Antiqua,Book Antiqua]_of significant complications, morbidity and/or mortality, as well as co-morbidities, associated with that patient's presenting problem(s), the diagnostic procedure(s) and/or the possible management options. _[/FONT]
[FONT=Book Antiqua,Book Antiqua]_The complexity of MDM should be documented accordingly and not inferred or implied. For each encounter, an assessment, clinical impression, or diagnosis should be documented. Physician MDM is critical to determine the overall level of care provided during a patient encounter. MDM may vary on a visit-to-visit basis depending on the patient's condition and what the physician performed that day. The fact that the patient has an underlying disease or co-morbidity is significant only if their presence significantly increases the complexity of the MDM. Only conditions that impact the encounter are determining factors that affect the level of E/M service. The current status of the patient's diagnosis is also a determining factor i.e. stable, improved, worsening etc. Diagnoses count in the MDM leveling only if they impact the presenting problem. Generally, decision making with respect to a diagnosed problem is less complex than an identified but undiagnosed problem. _[/FONT]
[/FONT]


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## kmaher

Thank you everyone for all the help thus far.   I'm from Michigan so I do know that some of these things vary from state to state, so I will contact our local insurance carriers on if they use MDM as one of the three components on determining the level and set a policy for the standards of auditing at our facility.    I'm sure I'll have lots of questions as I venture forth in this new position so thank you and I look forward to more interaction.


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## dclark7

This is from the Anthem Blue Cross CT Professional Reimbursement Policy, Documentation and reporting Guideliens for E/M services: _Although CPT coding guidelines do not specify which two out of the three key components must meet or exceed the stated requirements to qualify for reporting a particular level of E/M for an established patient visit, *Anthem requires that medical decision making be one of the two key components used to determine the E/M code level selected*. The other component can be either patient history or physical examination._

This became effective on 12/1/11 and can be found under the reimbursement policies section of their website. Most of the insurance require a log-in to go to the reimbursement section, but it's a good place to check.


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## Pam Brooks

dclark7 said:


> _*Anthem requires that medical decision making be one of the two key components used to determine the E/M code level selected*. The other component can be either patient history or physical examination._


 

NICE! Connecticut's lucky, you even have the casinos! LOL! Have a good weekend!


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