Wiki E/M Coding Based on MDM (Physician Practice)?

[staceyhibbert@gmail.com]

I have been coding for about six months now and I recently received some feedback on an official audit that was done on a couple of my providers. It was noted on the report, for example, that for established patients if the history and exam portions of the visit met a 99214, but the medical decision making of the same visit met a 99213, the visit should have been coded as a 99213.

I'm wondering if the accepted practice is to now always use the MDM plus either the history or exam portions to determine your E/M level when only 2 out of the 3 components are required? Or are you using just the history and exam portions in order to code at the highest level possible?

We are going to be having a discussion about this topic at work in a few days, so I'm interested in hearing what methods other coders are using. Thanks in advance!

 

[Pathos]

CPT book explains that for any Established visits, two of the three E/M components (History, Exam or Medical Decision Making [MDM]) should be counted against the level of service. I have yet to officially find something from either AMA or CMS that specifically states, the MDM has to be one of the two components which determines the Established visit level. The best I can find is the Medical Necessity, which is a very vague term and my MAC even states it's not quantifiable.

However, many coders and even some from AAPC have opinions that suggest MDM = Medical Necessity (MN), or at the very least leans heavily towards MN; thus should be one of the E/M components when determining Established/Subsequent visits. Our practice has also adopted this way of thinking in regards to Established/Subsequent E/M component selection. I tend to agree with this mindset as well. CMS is hinting that the upcoming revamp of E/M guidelines might also focus more on the MDM and less so on the other two E/M components.

All that said, the current state of things still beg towards MN. Did the provider spend a lot of time taking the patient History, did a Detailed/Comprehensive Exam, both Medical Necessary, but discovered that the problem was fairly minor? If we focus on History and Exam = 99214. If we look at H/E and MDM = 99213. Since AMA and CMS neither have given us a clear answer, I am afraid mine will be a bit muddled as well. Hopefully in a few years when CMS has completed their E/M guidelines revamp, we will have some clearer rules.


CMS E/M guidelines 1995/1997

 

[johnpiaskowski]

Mdm

This is a grey area that is not yet thoroughly spelled out. The only advise I can give is to ask yourself "Can I defend my level of coding successfully with documentation and the extent of the patient's condition so the point that any reasonable person would agree?" If your answer is no, then rethink your level.

Each coder and auditor has their own bias, but we all should rationalize to the same general level. If you need more guidance, see the examples in the CPT manual under appendix C.

 

[gchmelewski]

If you go to the AAFP guidelines you will find that they say MDM should be the primary driver for code selection. says they urge you to routinely make MDM one of the two key components used for deciding if the patient's care is worthy of the 99215 code.
I too struggled with this.

 

[thomas7331]

Inflated E&M levels due to over-documentation is certainly something that all practices should be concerned about, but in my experience, routinely requiring MDM to be met in order to charge a level is a poor solution to the problem and can result in improper under-coding, and if done over an extended period of time can in turn cause substantial loss of revenue to physician providers. Comparing MDM to the E&M level is more effective as a check on the highest level of codes, e.g. 99205/99215, but doesn't work well as an across-the-board fix to the problem. I recommend that practices evaluate their documentation carefully to try to understand what factors may be contributing to up-coding and address the root causes in cooperation with the providers to ensure that both documentation and coding are of good quality, rather than taking the short cut of coding all E&M based on MDM.

 

[TTcpc]

I agree with Thomas in the concern regarding over-documentation. I am curious if others are finding that when you talk to a provider regarding the history and exam always being detailed/comprehensive (possible over-documentation secondary to the EMR templates) versus the medical decision making that they often admit to over document in the first two areas, but leave out things in the MDM documentation that could support the higher level. For instance, I've met with several providers recently who were not aware of the new problem to examiner (thought that this was only for new patients and it wasn't clear if the problem was truly new to them or note) or independent visualization vs just review of the interpretation report, and other things all under the MDM section of the audit tools that if documented would earn them higher MDM. Many of them I meet with don't realize the importance of clear documentation and calculation of the MDM.