Wiki EM MDM

[bmellerio@yahoo.com]

As the guidelines state for an existing patient. you need 2 out of 3 to get a 99214 99215 99213 exc. 99214 detailed exam, detailed Hpi or moderate MDM. as the guidelines say 2 out of 3 for existing patient. or does it mean moderate MDM is a must and either detailed HPI or Detailed exam to do a 99214. My head coder is saying no matter what , the MDM must be one of the 2 out of three. the guidelines do not say that. your answer would be very helpful and i would not show it to this person. its for my own knowledge

 

[Pathos]

The official CMS guidelines do not state that the MDM must be one of the 2 E/M components to bill an Established patient visit. This sounds like an internal policy, which my previous employer shared as well.

That being said, the new E/M changes coming for 2021 for CMS will focus exclusively on the MDM when determining an E/M level. There are other major changes for 2021, but this is one of the more relevant to your questions.

 

[fl4paws@aol.com]

As the guidelines state for an existing patient. you need 2 out of 3 to get a 99214 99215 99213 exc. 99214 detailed exam, detailed Hpi or moderate MDM. as the guidelines say 2 out of 3 for existing patient. or does it mean moderate MDM is a must and either detailed HPI or Detailed exam to do a 99214. My head coder is saying no matter what , the MDM must be one of the 2 out of three. the guidelines do not say that. your answer would be very helpful and i would not show it to this person. its for my own knowledge

In real world your co-worker is probably correct a lot of the payers request MDM to be one of the 2 out of 3 but for the E&M exam certification which I struggle to obtain and AAPC it does not need to be part of the 2 out of 3. I hope this helps you understand how you are both correct depending on what situation you are in. Renee VP of DB chapter.

 

[thomas7331]

I agree with the above responses. MDM does not have to be one of the three under CPT or CMS published guidelines.

Some practices and payers may require MDM to be one of the three under their own internal auditing guidelines. This is usually implemented when providers inflate their documentation of the history and exam beyond was is reasonable or necessary for a particular condition, and the rule of requiring MDM is implemented in order to avoid the inflated coding that could result. In my opinion and experience, this rule is an imperfect solution for provider documentation problems, and if applied without across the board without care or discretion, is inappropriate and results in incorrect coding.