Wiki E&M level

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BhavinK

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Can anybody provide me suggestions on following topic,

In established patients i am facing problem in assigning e&m levels. Our mid party auditing team suggested that in established patients ( 2 by 3 components from history, exam and MDM) we need to take any 2 which are highest. By these we are billing some encounters in which physicians contribution towards collecting HPI from patient and performing physical examination rather then resolving/attending patient complains. We are doing these we are over charging patient for physicians service which is actually a frauding. So my concern is whether it is ethical or not.

If anybody have any idea what we need to do or by any means we can convince auditors. Help will be appriciated.

Appologies if i am wrong at any point. Corrections are welcome.
 
There's an unwritten rule that indicates that MDM and one other key component should result in determing the level of E&M visit, but nowhere is this a requirement. Some organizations (such as mine) sets the EHR to calculate in that way; specifically because MDM allows us to quantify the provider's thought process and patient problem/status/treatment. In truth, medical necessity should be the criteria for code selection. Medical necessity and MDM are not one and the same.

An example of when MDM would not contribute to the code selection (and medical necessity does) would be if a patient returned to an oncologist for a visit six months after completing chemotherapy for breast cancer. The oncologist takes a detailed history, performes a detailed exam, but the one condition (cancer) is established and stable, labs are normal and no treatment is in the works. That gives us low MDM, but the HPI and exam would warrant 99214 since that amount of work is medically necessary to arrive at the conculsion that the breast CA is indeed stable.

Counting bullets is just one part of auditing. The other part is considering the nature of the presenting problem and determining if the associated work warrants the level of service the provider wishes to bill. Good question.
 
Thank you Pam for providing bried explanation on my doubt. As you explain by taking scenario of CA, it is justify the medical necessity. But in case where our physician giving comprehensive History & Examination in his/her all medical records will it justify?
 
Only if it's medically necessary to do that without also needing higher medical decision making to support the level. Be careful that the excessive documentation in comparison to the lower MDM isn't just extra words that aren't related to the complaint. Each note must be reviewed and analyzed individually. You may not assume that if they always have comprehensive history and comprehensive exam that the medical necessity is supported. This is a sure fire way to get into trouble with the payers and the provider having to pay back money. Take your time and make sure that the nature of the presenting problem meets the level of service.
 
Pam Brooks said:
Only if it's medically necessary to do that without also needing higher medical decision making to support the level. Be careful that the excessive documentation in comparison to the lower MDM isn't just extra words that aren't related to the complaint. Each note must be reviewed and analyzed individually. You may not assume that if they always have comprehensive history and comprehensive exam that the medical necessity is supported. This is a sure fire way to get into trouble with the payers and the provider having to pay back money. Take your time and make sure that the nature of the presenting problem meets the level of service.
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You are absoulutely correct Pam.:eek:
 
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