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kellyl

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I am having a problem with an E/M 99212 vs 99213. I if I have an expanded problem focus HPI and an expanded problem Exam with a straightforward MDM what code would you use?
 
I agree with cheermom. Medical necessity should be the determining factor for the selection of the level of service for an established patient even if the other two key components exceed the level of service for the complexity of the patient encounter. I would have to look at the documentation, but if medical necessity only supports straightforward MDM, then I would go with 99212.
 
I agree with the medical necessity issue, but since I was not given any other supporting information, such as diagnosis, I had to go with what I was given.
 
99212 vs 99213

Thanks for everyone's input, I agree with both 99212 and 99213, so why am I so confused? The AMA CPT state's "For an established patient visit, two of the three key components (history, exam and medical decision making) must meet or exceed the stated requirements to qualify for a particular level of E/M service. It does not say that Medical decision making is the deciding factor. How do you explain this to your physicians.
 
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Per a CMS memorandum: “Medical necessity of a service is the overarching criterion for payment in addition to the individual requirements of a CPT code. It would not be medically necessary or appropriate to bill a higher level of evaluation and management service when a lower level of service is warranted, The amount of documentation should not be the primary influence upon which a specific level of service is billed. Documentation should report the level of service reported. The service should be documented during, or as soon as practicable after it is provided in order to maintain an accurate medical record.”

SOURCE: Medicare Claims Processing Manual, Chapter 12, Section 30.6.1
 
CPT vs CMS

The CPT is owned and published by the AMA. CMS (i.e. Medicare) doesn't always agree (for example consults).

Medicare's overarching criteria for medical necessity does not automatically equal MDM. Why? A physician may feel it is medically necessary to perform a higher level of exam or obtain more data in order to rule out a more serious diagnosis.

Only the provider knows what was truly medically necessary to arrive at the ultimate conclusions. Just because the ultimate MDM is straightforward doesn't mean that the EPF exam and EPF history were not medically necessary.

For an established patient you need to meet or exceed 2 out of 3. EPF history and EPF exam gives you a 99213. It is what it is.

Hope that was helpful.

F Tessa Bartels, CPC, CEMC
 
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