Wiki 2/3 Rule using MDM for Est Pt

[madsmacpc]

I work for an Oncology office and our providers are requesting documentation to support the necessity of the MDM to be used as ONE of the elements in determining the level of service when billing an established patient office visit.

We often find with our EMR system that a Comprehensive HPI, ROS, PFSH is easily obtained and our providers generally do a complete exam. If this is the case we would be billing majority level 5's . We are communicating with the providers that the MDM (Amount of Complexity of Data Reviewed as well as the number of Dx Treatment options and the Table of Risks) is the driving factor of the level. We are requiring that the MDM is one of the 2/3 elements when billing an established pt. This is always how we have been taught and how we have billed.

Now they want documentation from CMS to support such. Does anyone know where I can find documentation to support this ? Are we billing this incorrectly by doing this?

Any help would be appreciated. Thank you !!

 

[mhstrauss]

I work for an Oncology office and our providers are requesting documentation to support the necessity of the MDM to be used as ONE of the elements in determining the level of service when billing an established patient office visit.

We often find with our EMR system that a Comprehensive HPI, ROS, PFSH is easily obtained and our providers generally do a complete exam. If this is the case we would be billing majority level 5's . We are communicating with the providers that the MDM (Amount of Complexity of Data Reviewed as well as the number of Dx Treatment options and the Table of Risks) is the driving factor of the level. We are requiring that the MDM is one of the 2/3 elements when billing an established pt. This is always how we have been taught and how we have billed.

Now they want documentation from CMS to support such. Does anyone know where I can find documentation to support this ? Are we billing this incorrectly by doing this?

Any help would be appreciated. Thank you !!

You will not find this from CMS. MDM IS NOT required to be 1 of 2 out of 3 elements in determining the overall level of visit. Your clinic's internal policy may be this, but there is no official guidance. I've read others posting here that their individual MAC's require this, but I've never seen it in writing directly from any MAC--you should check with yours.

Please see this ealier thread discussing the same issue. It has some great points, I've saved it and refer back to it often.

https://www.aapc.com/memberarea/forums//showthread.php?t=94722


Hope this helps!