# Medical Decision Making - coding for established patients



## lcterry (May 7, 2009)

We had a discussion in our office today about coding for established patients, our doctors only want to use the 2 components of History and Exam, and not MDM.

I have read some where that medical decision making is always one of the 2 of the 3. I attended a seminar where is was told to me also.  I need documentation to back us up.

If this is not the case then I need further guidance.

We had an example, of a patient coming in with a sinus infection, and the history and exam met a level 4, but the MDM only met a level 2, and we were told since the history and exam met a 4 we were to code that as a level 4.

I'm afraid if we were audited then we would be dinged for this.  

Does anyone have a Medicare link to help with this?

Thanks


----------



## rthames052006 (May 7, 2009)

lcterry said:


> We had a discussion in our office today about coding for established patients, our doctors only want to use the 2 components of History and Exam, and not MDM.
> 
> I have read some where that medical decision making is always one of the 2 of the 3. I attended a seminar where is was told to me also.  I need documentation to back us up.
> 
> ...



I think your thinking of Medical Necessity. If you look at your cpt book for Est pt's you can use any 2 of the 3 key components to get to your level of service.  The example you have listed would be a level 4 based on the history and exam in this case but the question becomes was the exam "medical necessary".  Just for the sake of arguement what organ systems were examined on this particular case.


----------



## jciriello (May 7, 2009)

The history and exam are NOT enough to bring this up to a level 4 exam.  All three components are necessary to make up the level. The MDM is derived from the workup (i.e.labs and/or xrays).  In this case, as sinus infection, the most she got in a physicians office was probably an Rx and, therefore, would not exceed a level 3 (99213).  Without an Rx this would be a level 2 (99212).  
In the ED, if the pt had an extreme headache and was given a CT which revealed a sinus infection, *with* an Rx given, would be a level 4 (99284).  This is by Medicare guidelines.  History and exam only cannot bring you to a level 4.


----------



## lcterry (May 8, 2009)

Thanks for your responses, this is what I found at Pinnacle(they used to be our Medicare carrier, until Trailblazer)

The appropriate level of service can only be determined based on the documentation in the medical record.  The complexity of medical decision making is the *primary indicator *of the appropriate level of service.  Documentation for E/M codes must contain the specified number of key components in the CPT definition of the code, based on the condition of the patient.  The condition of the patient is indicated by the medical decision making aspect of the required components. 

For example, at least two of three key components must be met for subsequent hospital or established patient office E/M services.  *One of those key components is the level of decision making.* *If the levels of history and exam meet the two key components for the level of service billed but the medical decision making is lower than that required for that code, the service will be re-coded to the code which corresponds to the level of decision making reflected in the documentation.  The history and exam will meet or exceed requirements for the lower level of service, but recoding would be appropriate based on the condition of the patient.*
According to the 1995 and 1997 Evaluation and Management Guidelines, the levels of E/M services recognize four types of medical decision making (straightforward, low complexity, moderate complexity, and high complexity). Medical decision making refers to the complexity of establishing a diagnosis and/or selecting a management option as measured by.

I haven't found this in writing from Trailblazer, but I will call and see if it is in writing.

Thanks again!


----------



## LLovett (May 8, 2009)

Established visits are 2 of 3, the visit has to be medically necessary but medical decision making is not the same thing as medical necessity. Generally the level of MDM is one of the key components used in an established visit but it doesn't have to be.

http://www.cms.hhs.gov/apps/er_report/preview_er_report.asp?from=public&which=A&reportID=8&tab=5

The above is from CMS and clearly states you just need 2 of the 3 it does not say one has to be MDM. This statement echos the guidelines in CPT as well.



"CPT code 99214, office or other outpatient visit. The physician should typically spend 25 minutes face-to-face with the patient and perform at least two of the following procedures: a detailed patient history, a detailed examination, and/or medical decision making of moderate complexity."

I know Trailblazer has some funky rules that don't make any sense so they may have something else but this is from CMS. 

Laura, CPC


----------



## RebeccaWoodward* (May 8, 2009)

Laura,

I could not agree more.  Nice link too.


----------



## cheermom68 (May 8, 2009)

*Mdm*

Based on the post audit education that we went through with one of our family physicians, that visit would be re-coded either to a level 2 or 3 (I'm not sure because I don't have all the info) probably a 3 if this was a new problem for the patient.  It definitely would not be a level 4 unless their were further complications or comorbidities that I am not aware of.  The focus is definitely on medical necessity.  Medical decision making is not the same as medical necessity, however according to the CMS educators it is a main determining factor in the selection of a level.  An encounter may meet the history and exam for a level 4, but based on the MDM needed for that problem (especially in an established patient), were they really necessary? They were downcoding level 4 and 5 visits that had either detailed history and exam, or comp history and exam, along with 4-6 chronic conditions in an elderly patient on multilple meds.  They said that as long as the conditions were stable, the MDM and medical necessity did not meet level 4 or 5 but they downcoded them all to level 3's.  We did not necessarily agree with them, but that really doesn't matter.  We have to play by their rules.  
Just wanted to give all a heads up on this, we were very surprised by the results.  After review, we felt the level 5's should meet a level 4, but according to CMS auditors, they were a level 3.


----------



## rthames052006 (May 8, 2009)

katmryn78 said:


> Established visits are 2 of 3, the visit has to be medically necessary but medical decision making is not the same thing as medical necessity. Generally the level of MDM is one of the key components used in an established visit but it doesn't have to be.
> 
> http://www.cms.hhs.gov/apps/er_report/preview_er_report.asp?from=public&which=A&reportID=8&tab=5
> 
> ...



Thanks Laura,

The poster of this thread must have a "funky" carrier with funky rules... I too agree with the link and thats what I was basing my reply on.  Glad to know I was on the right track.

Have a good weekend!


----------



## cheermom68 (May 8, 2009)

*Mdm*

The education recieved was from CMS, not a "funky carrier".


----------



## LLovett (May 8, 2009)

Glad to be of assistance.

As far as an audit where they dropped patients on multiple medications with multiple conditions down to 3's, I think I would fight that out to the highest level possible if the documentation supported it. 

A detailed or comprehensive exam may not be medically necessary every time if they are stable but the History should always be a minimum of detailed in this scenario (based on 97 guidelines) and you have moderate MDM. 4 conditions stable is 4 dx points 2 or more stable chronic illness is moderate so is Rx management. That is a 99214, I could understand them dropping 5's down on this type of patient to a 4, but no lower.

Of course, I guess I am lucky to be dealing with WPSMedicare, they seem to be pretty laid back and follow CMS guidelines.

That is something I will never understand, the FI is processing claims for CMS, why do they get to make up their own rules instead of following the multitude of rules already in place by CMS?


Have a great weekend!

Laura, CPC


----------

