# Medical decision making



## WFassnacht (May 23, 2013)

Is medical decision making still the overarching factor when you go to determine  your level of care. If this has changed can you please provider me with a website.


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## MikeEnos (May 23, 2013)

*Medical Decision Making* NEVER WAS the "_overarching criterion for payment_."  You're thinking of _medical necessity_.  Those to terms do not mean the same thing, and are not interchangeable.


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## suemt (May 28, 2013)

I don't see where the question has anything to do with payment.  

It is true that you can do HPI and exam til the cows come home, but your MDM needs to support the level of service you wind up billing.  

An exception (of course there is always an exception!) would be time-based coding.


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## MikeEnos (May 28, 2013)

I was completing the quote, Sue.  The OP used the term _overarching factor_, in the context of asking  about medical decision making determining the level of care.  That phrase is based on an actual quote from CMS Claims Processing Transmittal 100-04-178 regarding the selection of a level of evaluation and management service:



> *30.6.1/Selection of Level of Evaluation and Management Service
> A - Use of CPT Codes*
> Advise physicians to use CPT codes (level 1 of HCPCS) to code physician services,
> including evaluation and management services. Medicare will pay for E/M services for
> ...



Given the context of the question, I wanted to make clear that the medical decision making is not the overarching criterion, and it never was.  CMS states that the medical necessity is the overarching criterion.  Be aware that those two phrases are not the same, and are not interchangeable.

While you are correct that theoretically the provider could always document a comprehensive history and exam, that doesn't mean they are all level 5's - the medical necessity should determine the level of service.  That does NOT mean that the medical decision making complexity limits the level of service.  Just answering the question: "Is medical decision making still the overarching factor when you go to determine your level of care?"  No - it isn't, and it never was.


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## mitchellde (May 28, 2013)

well put Mike!


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