# What E/M code woud you allow in Audit?



## SueTeal

Our Practice is doing an extensive internal audit on E/M coding. A primary care provider documented a detailed history, detailed exam, and low medical decision making on a patient with a cold which is actually resolving. The patient is in their 30's.  I realize 2 of the 3 key components meet and support the 99214, but isn't this where nature of presenting illness (the contributing factor) comes into play? I don't think this patient is at a moderate risk of mortality if they left the office untreated. The risk is low or even lower. That's the thought process I use. I'm having a dispute with another Coder on the Team and would like some help with this interpretation.  The patient does not have history of Asthma or COPD or any other comorbidities that might influence a higher level of complexity.


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## LLovett

Medical necessity is the driving factor, but MDM is not what determines medical necessity. It can be a good indicator but it is not the end all be all.

I have no idea what happened in your case but I use this type of a visit as an example to my providers all the time. In fact I just had my daughter in for the same basic thing yesterday.

A detailed history is done along with a detailed exam. You have a new problem with no work up (3 pts), obviously no data pts, so it comes down to the table of risk to determine your MDM level. If they give a script at this point you are at moderate. If they don't you are most likely stuck at low (OTC) or even straight forward (rest). 

So the only difference between an undeniable 4 and a 3 or even a 2 is where they fall on the table of risk. They are doing the same work in obtaining hx and doing exam. They have the same dx and work up pts. They have the same presenting problem. If the doctor had written a script you would not even be questioning the level, it would be a straight 4.

Unless this was a follow up visit, I say the 4 is correct. 

Just my take on it,

Laura, CPC, CPMA, CEMC


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## rthames052006

katmryn78 said:


> Medical necessity is the driving factor, but MDM is not what determines medical necessity. It can be a good indicator but it is not the end all be all.
> 
> I have no idea what happened in your case but I use this type of a visit as an example to my providers all the time. In fact I just had my daughter in for the same basic thing yesterday.
> 
> A detailed history is done along with a detailed exam. You have a new problem with no work up (3 pts), obviously no data pts, so it comes down to the table of risk to determine your MDM level. If they give a script at this point you are at moderate. If they don't you are most likely stuck at low (OTC) or even straight forward (rest).
> 
> So the only difference between an undeniable 4 and a 3 or even a 2 is where they fall on the table of risk. They are doing the same work in obtaining hx and doing exam. They have the same dx and work up pts. They have the same presenting problem. If the doctor had written a script you would not even be questioning the level, it would be a straight 4.
> 
> Unless this was a follow up visit, I say the 4 is correct.
> 
> Just my take on it,
> 
> Laura, CPC, CPMA, CEMC



Well stated Laura!


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## SueTeal

This one particular scenario was a follow up visit.  Thank you for your response.


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## Pam Brooks

I agree with the level 4, unless your CMS contractor is NHIC (as is here in NH). They have gone so far as to indicate that MDM should be the determining factor in E&M code selection, when 2/3 key components need to be met.  

Isn't it fun when CMS doesn't agree with CPT?


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## 1071471

I know of some companies even adopting policies that have the MDM as the driving factor even with the 2 out of 3. Maybe this scenario/issue can be addressed in the future within your company. 

The physicians I work for elected not to adopt this policy because they are made up of multiple specialties and it wouldn't be fair (lack of a better word) to all physicians. For example, Medical Oncology and Hematology practices. 

Good luck!


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## nuenz@yahoo.com

i agree with Laura, great explanation.
Danielle Carroll


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## Orthocoderpgu

If the cold was the cheif complaint and the ultimate diagnosis, I would say that this is over-coded and the doc did too much work. I can see getting an easy Extended HPI especially if the doc knows what elements to focus on. The MDM is low. So the key factor is the exam. I can see getting an EPF exam out of this. But to get to a detailed exam you would need 12 exam bullets. And for a simple cold, I can't see getting 12 exam bullets and saying that all of them are "Medically Necessary".


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## LLovett

You don't need 12 bullets do get a detailed exam under 95 guidelines. I don't personally like 95 but many times it is more advantageous for the provider and that is what the auditors are supposed to go with, whichever set of guidelines that are more advantageous to the provider.

Laura, CPC, CPMA, CEMC


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## dballard2004

If this is a follow-up visit for a cold that is resolving, I don't see a level four here.  I say a level three hands down.


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## LLovett

Dawson,

Please explain your reasoning. 

An established problem stable or improved is only 1 Dx point. If you are basing the level on the MDM, which apparently you are since history and exam are detailed, this would put you at a 2. 

Thanks

Laura, CPC, CPMA, CEMC


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## yankeegirl0919

if a resolving cold with no meds is a level 4, i am in big trouble...this is a straight 2


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## ShellieSulzberger

I would say a level 3 - what is the medical necessity for a detailed history and/or examination on a cold that is resolving with no co-morbidities. I think that would be hard to defend.  Just my opinion.


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## FTessaBartels

*Cold = Self Limited Problem*

A cold is a self-limited problem on the table of risk. Just because you give a script when patient insists doesn't make this moderate risk.  ESPECIALLY if you are talking about a F/U visit.

Actually I've discovered the cure for the common cold - *Chocolate Ice Cream*
Have a bowl of chocolate ice cream every day and in 7-10 days your cold will be gone! Works every time.

F Tessa Bartels, CPC, CEMC


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