Wiki E/m coding

[Aledford]

HELP! I need advise. I am currently performing random audits on few providers. I came across a follow up appt for chest pain after a stay in the hospital. Looking back through the record pt's first visit was due to heartburn/ reflux symptoms. Then another follow up visit for the same problem in 2008. Per the note there is enough documentation for a level 5 based upon History and exam. The MDM is low, as there were no tests ordered only a modification made to Rx. Pt has Medicare and with the MDM being low I don't feel a level 5 visit should be billed. What do you think?

 

[martinni1974]

Even though the CPT code may only be requiring 2 out of the 3 key components be met, if the medical necessity (nature of the presenting problem), is not also in line with the code selection than you shouldn't chose the code based solely on history and PE. The nature of the presenting problem must also warrant a high level E&M code.

The only other option is if time was a factor and was appropriately documented.