A few years back, I was involved as an auditor and provider educator with a practice that used MDM as a required element for E&M levels as you describe for this same rationale. After about two years of struggling with this, doing research, discussing the issue with many other auditors and professionals, and dealing with an enormous amount of provider dissatisfaction due to down-coding that resulted from this practice, I came to the conclusion that an across-the-board policy of using MDM as a required element for all E&M codes is not an effective way to ensure that levels accurately reflect medical necessity. I believe that this approach may work fairly well as an approach for high-level E&M codes (i.e. 99215 and 99214) and in cases where EHR entries are routinely inflated by templates or copy/paste that results in documentation that does not accurately reflect the history and exam work that providers are actually doing, but is a very flawed method for addressing up-coding due to inflated documentation for all situations.
While medical necessity is certainly important and should be a consideration in coding, substituting MDM for medical necessity, in my opinion, ultimately results in incorrect coding and undervaluing of provider work. Assessing medical necessity of any service requires a clinical background in order to understand why a provider must investigate certain symptoms or examine certain body areas or systems. The fact that the ultimate decisions a provider makes may be of low complexity does not mean that the history that was reviewed or the exam that was performed was automatically medically unnecessary. It is not correct coding to simply 'disqualify' a history or exam as being too high just because of the MDM level. In order to accurately address this issue, one needs to have the clinical training to be able to say specifically which elements of the documentation do not represent standards of care that a provider needed to include in that service, and this is not something that someone with just a coding training alone can do.
This can be a challenging issue and there is no easy fix. Just my opinion of course and every situation is unique, but I think that if a practice has a problem with inflation of E&M levels due to excessive documentation, this is best addressed as a collaborative effort between the coders and the providers with input from both. Coders can help providers better understand the expectations of payers and how to efficiently document their services to meet requirements, while providers can also guide coders in understanding the rationale and medical necessity of their work and give coders the tools to better understand when a service is or is not supported and defensible in the event of an audit. Ultimately, the best solution is not necessarily the easiest one, but the one which will result in improved documentation and accurate coding both.
