Wiki Established Patient Office Visit - Determining Level of Service

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WDStr33t

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We are having a bit of a debate in the office.

Please keep in mind that these are Medicare/Medicaid patients if that makes a difference.

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For established outpatient office visits, the documentation only requires TWO out of THREE of the required level of History, Exam and Medical Decision Making.

This being the case, if you have a note that contains a Comprehensive History, Comprehensive Exam, and Low Complexity MDM would that not be completely billable as a 99215? There is a divide between people wanting to bill based on the documentation and the information provided, and people wanting to bill based solely on the Medical Decision Making who would bill the above as a 99213.

If anyone has any information that could help swing this disagreement one way or the other, it would be greatly appreciated.

Thank you.
 
Level 5 visits generally entail life-threatening conditions on the DOS.

Peace
@_*
Most life-threatening conditions would involved a very high level of medical decision making.
 
liloe517 said:
https://www.cgsmedicare.com/partb/mr/pdf/99205.pdf


https://www.cgsmedicare.com/partb/mr/pdf/99213.pdf

Here are some fact sheets that can help you determine the level to bill. Based on the description you gave I would say that it is a 99213.
Click to expand...


You linked to 99205 fact sheet, not 99215. New patients require all three key components. Established patients require only two of three key components.

Here is the CGS fact sheet for 99215. It clearly states only 2 of 3 key components are all that is needed.

https://www.cgsmedicare.com/partb/mr/pdf/99215.pdf

The key is the medical necessity (different than medical decision making) of the comprehensive history and comprehensive exam.

If the provider can truly defend the medical necessity of a comprehensive history and comprehensive exam, then that is all that is needed to choose a 99215. The MDM level of complexity can be lower.


Here is a good article explaining Medical Necessity vs. Medical Decision Making.

https://www.racmonitor.com/warning-medical-decision-making-and-medical-necessity-not-one-and-the-same
 
I agree with Karl's comments above which summarize this well. This is a topic that has been discussed a lot on this forum, and there are also many good articles and webinars from AAPC and other sources about appropriate choice of E&M levels and how medical necessity and MDM should play a role. I'd recommend Stephanie Cecchini's talks in webinars in particular, but also suggest doing some searches to find these materials and reading extensively if you wish to develop an in-depth understanding as it's too complex a topic to try to capture in quick answers here. I'd just add a few of my own thoughts.

As pointed out, CPT guidelines state that two out of three levels must be met or exceeded but do not specify that MDM must be one of these. Some payers and some practices do have internal policies that require MDM to be one of the two - but this is not a coding guideline. The reasoning for this for this practice has usually been that 1) CMS and other payers require that the level of service be no higher than that which is medically necessary for the patient's problem; and 2) some providers and EHR systems often inflate the levels of history and exam beyond was is necessary, resulting in inflation of E&M levels. As a result practices have adopted MDM as a way for coders to assess the medical necessity of a service to prevent up-coding, but it's important to note that these two are not the same thing.

Personally, having been a part of a practice that used MDM as a required component, I found it to be unreliable and often resulted in under-coding and unfairly penalizing providers, especially in cases where significant provider work in the history and exam resulted in a decision that the patient's problem, so I do not advocate it. While it's important to be conscious of medical necessity when choosing E&M levels, medical necessity is ultimately a clinical decision that requires the training and background that providers have, and I've found it's best to involve providers in these kinds of decisions and in the creation of any guidelines that involves having coders deviate from the CPT and other established guidelines. Having examined many notes with providers over the years, I have come to appreciate that the medical necessity of any given service is often not apparent to someone without clinical training, and coders should not undertake this without the collaboration of their providers.
 
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I did attach the wrong one, sorry about that.

Also thank you for the additional info in regards to the MDM with the established patients.
 
Thank you for the replies.

Definitely a middle ground found between looking strictly at the documentation and looking solely at the MDM. In case anyone else is wondering, I was also pointed to Section 100-04 of the CMS Claims Processing Manual which states "Medical necessity of a service is the overarching criterion for payment in addition to the individual requirements of a CPT code."

Section 100-04 Chapter 30.6.1 (A) of the Medicare Claims Processing Manual. https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/downloads/clm104c12.pdf
 
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