Wiki Auditing An E/M Code

[CindyWeems]

Pt was seen for 1 stable chronic condition - have expanded problem focused history, Detailed exam, MDM is straight forward. According to MCR worksheet, it is a 99213, but Medical Decision Making is the overriding factor and is a 99212. Provider coded 99212. Would you change to 99213 or leave as 99212?

 

[thomas7331]

Medical Necessity is the overriding factor, not MDM, although the two are sometimes equated. If the level of detail in the history and exam is medically necessary, then the 99213 is warranted. Some stable chronic conditions do require more careful monitoring than others, so a more extensive History and Exam may be necessary even if the MDM is SF. But if the exam is detailed only because the provider has populated the documentation with extra information that's irrelevant to the presenting problem, then you'd want to go with 99212.