Wiki E&M % Ratio

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msingh23

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I will appreciate some feedback on % ratio of E&M levels providers billed deem reasonable. My facility has two orthopaedics doctors, upon my review of their documentation I am justifying for E&M 99204 and E&M 99244 (levels 4) for most maybe 95% or more of their new patients.
Their MDM are as follows:
1.Pain, new problem to provider, provider ordering X-ray or MRI to r/o ?????
2.Pain, new problem to provider, provider given Rx for pain meds.
3.Pain, new problem to provider, provider given Rx for pain meds & ordering X-ray or MRI .
Note; Physical therapy may also are added to the above MDM


History = Comprehensive (4 or more HPI Element, 3 PFSH, 10 ROS system)
Exam = Comprehensive (8 organ systems)

Thank you in advance for responding.
 
I would be looking into having a clinical review for medical necessity with those numbers. Not that I agree with the bell curves but why is it medically necessary for an orthopedic provider to do a comprehensive history and exam on pretty much every new patient and they aren't even planning to do surgery?

I have had quite a few orthopedic providers tell me they will never get above a 3 for a new patient because it is not medically necessary for them to do the comprehensive history and exam even though they may have Moderate or High MDM.

It may be totally correct and on the up and up but I would want someone clinical to review for the medical necessity piece just to be sure.

There are those that teach to work backwards from MDM and perform the levels of history and exam based on your MDM level. As we all know medical necessity should be the driving factor. MDM and medical necessity are not the same thing.

Just my 2 cents,

Laura, CPC, CPMA, CPC-I, CEMC
 
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