# MDM making our decisions



## kterry0474 (Dec 4, 2013)

My office has recently had an audit by an outside vendor. This was set up by our higher ups. Our providers had to get 9 out of 10. correct in order to pass. What I found was they do nto like us billing level fours, almost all we downcoded. I audited the charts myself adn recieved confirmation from the other CPC in the office. I contacted our compliance officier and she stated ever though we had 2 out of 3 the decision making was low (in their minds) and they downcoaded then to level 3. I have attached a chart note as an example. 
She stated that the main decision is the MDM because that is what AMA, CMS and OIG are stating and should be the deciding factor. Please note that we ONLY count what is pertinant to the visit. I would appreciate any information that you may give me!. 

Established Patient Visit   health depart
PCP:  HEALTH DEPT
CHIEF COMPLAINTS: Followup of Atypical Squamous Cell Changes Of Undetermined Significance Favor Benign.


HISTORY OF PRESENT ILLNESS:

On 11/04/2013, a 34 year old female, LMP 10/30/13 , G  2  P 2 0 0 2 using as her birth control tubl ligation.


- presents for pap. was seen5 months ago after abn pap at health dept. pt is HIV pos and has longstanding hx of abn paps, had LEEP several years ago. COlpo was done with nml findings. she is currently undergoing surveilence with pap q 6 months until 3 consecutive nml paps


HEALTH MAINTENANCE HISTORY (dates may be approximated):




REVIEW OF SYSTEMS:
General:     no fever, chills, or body aches
G/U:         no dysuria, urgency, frequency or incontinence. No abnormal menstrual bleeding or symptoms


GYNECOLOGICAL HISTORY:
  Current Contraception  - tubl ligation
   Last Pap Smear Date    - 03/2013
   Last Pap Smear Report  - abnormal by history
   Abnormal Pap Smear     - Hpv
   Last Mammogram Date    - None
   Bone Density Scan Date - None
   Colonoscopy Date       - None
   Breast Lump            - No
   Fibroids of Uterus     - No
   No. of  Sex Partners   - 5
   Ovarian Cysts          - No
   Sexual Abuse           - No
   Sexuality Concerns     - Burning
   STD's                  - HIV
   Unprotected Sex        - No
   Urinary Tract Infections-No
   Vaginal Infections     - BV in past, during pregnancy only in past and yeast in past
   Menopausal Symptoms    - night sweats
   Urinary Incontinence   - No
   Last Cholesterol Check Date - None

MEDICAL/SURGICAL HISTORY:
Infections - Chicken pox and HIV 
Illnesses - Bronchitis 
Accidents/Hospitalizations - car accident 
Surgeries - Tubal ligation, conbiotgy and Cesarean section
Emotional Problems - none


PRESENT MEDICATIONS:
1. 3 eye drops
2. asentress
3. norvair
4. prevista
5. vireid

ALLERGIES:
    NKDA


MENSTRUAL HISTORY:
   LMP                         10/30/13
   Amount/Duration             Normal
   Regularity                  Regular
   Menstrual Cycle Length      5-7 days

PHYSICAL EXAMINATION: 

VITAL SIGNS:

BP:    120/84 mmHg -



 Weight:     259.00 Lbs.
 Height:       63 In.          


 BMI:       45.87
 LMP:              10/30/13

GENERAL EXAM:
CONST.:  well nourished, well developed, no acute distress
NEURO:   alert, oriented x3, no focal signs, mood and affect appropriate

PELVIC EXAM:
VULVA:   no external lesions, normal hair distribution
URETHRAL MEATUS: no lesions, eversion, or stenosis
URETHRA: non tender, no masses, no discharge, well supported
BLADDER: no tenderness or masses, well supported
VAGINA:  normal rugae, adequate support, no discharge, lesions, or erythema
CERVIX:  no lesions, no discharge, non friable
UTERUS:  normal size, mobile, nontender, smooth in contour, normal consistency, adequate support
ADNEXA:  no adnexal masses, nodulularity or localized tenderness
ANUS & PERINEUM: intact w/o lesions, rashes, fissures, fistulas, or symptomatic hemorrhoids
RECTAL:  normal sphincter tone, no palpable masses

DIAGNOSTIC TESTS: 
  Thin Prep Pap /HPV Rflx 16/18



DIAGNOSES:
    1. Atypical Squamous Cell Changes Of Undetermined Significance Favor Benign Unchanged


PLAN NOTES:
pap collected, if nml, will repap in 6 months, if abn, will plan to repeat colpo. Pt understands


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## mlbaker1974 (Dec 4, 2013)

This is what I get - 
History EPF - 1 chronic condition (abnormal pap), HIV is mentioned but status not given, or location (cervix), duration - 5 months, modifying factors - HIV, LEEP and colpo (3 elements, brief), ROS - GU (pertinent ROS), Past history and social history (complete history).  
Exam - 14 bullets (detailed, '97), or 2 OS in detail (detailed, '95).  
MDM - Low - 1 established problem, stable 1 point, order/review pap/HPV 1 data point and low risk for one stable chronic condition.

Overall I would assign a 99213.

All states except virginia have a policy stating the MDM must be one of the 2 key components.

Hope this helps.


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## Lashel (Dec 4, 2013)

so we know that with an established patient we need two of the three key components to select our level of service. So what do we do when the MDM is low, but the exam and history are both detailed? Based on the two of three we should just be able to toss out the MDM. Unfortunately the over arching criteria according to CMS is medical necessity.  So someone might say "if the MDM is low" then was it medically necessary to do a detailed history and exam? There has been plenty of debate about this, and very experienced coders will often disagree. I think it is a gray area. I know of some offices who make it a part of their compliance plan, that the MDM must meet one of the two components. I can also think of examples where I believe that would be inappropriate. Let's say that a patient is coming in for follow up of a malignancy of some sort. We are going to be real thorough in our history and exam, because we need to make sure this malignancy is still gone or in remission. At the end of it all, the patient is fine and doing well, no additional work up, no evidence the malignancy has returned, nothing to review, no tests to order. This is going to be low MDM, but we still did the work of a level 4. In my opinion the history of malignancy supports medical necessity for a level 4, but again, just my opinion. 

Lashel CPC CPC-I CPPM CEMC


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## npricercm (Dec 5, 2013)

bakerml said:


> This is what I get -
> History EPF - 1 chronic condition (abnormal pap), HIV is mentioned but status not given, or location (cervix), duration - 5 months, modifying factors - HIV, LEEP and colpo (3 elements, brief), ROS - GU (pertinent ROS), Past history and social history (complete history).
> Exam - 14 bullets (detailed, '97), or 2 OS in detail (detailed, '95).
> MDM - Low - 1 established problem, stable 1 point, order/review pap/HPV 1 data point and low risk for one stable chronic condition.
> ...



Hi,
Would you please provide documentation that all states except Virginia have a policy stating that MDM must be one of the 2 key components?

Thank you
Nancy Price, CPC


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## LLovett (Dec 5, 2013)

*Documentation request*

I would also like to see this documentation regarding MDM being a mandatory component. I have documentation supporting the exact opposite from WPS Medicare.

http://www.wpsmedicare.com/j5macpartb/training/on_demand/_files/em-handout-3.pdf

Billed CPT 99212 requires 2 of 3 key components problem focused history and exam, and straightforward medical decision making. Documentation submitted supports up code to 99214 with detailed history and exam, and straightforward medical decision making per 1995 and 1997 E/M guidelines.


While it is not uncommon for facilities to make an internal decision that MDM is required to be one the components used in a 2 of 3 code and there are some carriers that require this as well, to the best of my knowledge this is not a CMS or AMA requirement. 

Thanks

Laura, CPC, CPMA, CEMC


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