Wiki Established PT E/M billing

[Anna L]

Recently I heard that when you code for Established PT E/M visit the leading key component must be MDM inorder to bill the appropriate code. My understanding is that two out of three of the components of the vist (history, physical and medical decision making) are required to determine the level of the visit.

However, a coder for another organization recently told us that one of the two components to determine the level for an established patient office visit must be medical decision making. The other component can be either history or physical.

Is it true that MDM must be one of the two components to determine the level of an established visit?

 

[Walker22]

Technically, it is not true since you must have only two of the three components to code a follow up visit. HOWEVER, having said that, if one of the components is not MDM, then you leave yourself open to having the payer deny the claim altogether as "not medically necessary". Think of it like this: You can do a comprehensive history and a comprehensive examination on a patient who's only complaint is a hangnail and technically qualify for a 99215, but is that really necessary? I find it is always more accurate if you include MDM as one of your components every time. You will get a more accurate code that way.