Wiki Highmark BCBS New Policy - MDM to be one of the key components

[Quaker]

Was anyone aware that Highmark BCBS implemented a new policy, effective 10/1/2017, requiring medical decision making to be one of the key components in selecting a particular level of an E/M service? According to the policy, they based this position in its interpretation of the 1995 and 1997 CMS E/M guidelines. I am just finding out about this policy and I'm concerned that HM is not interpreting CMS' E/M guidelines correctly AND they did a poor job communicating this new requirement to the provider community.

Link to policy https://hbcbs.highmarkprc.com/Claims-Payment-Reimbursement/MA-Medical-Policy-Interior

Can they really do this?

We all know that medical necessity does not equal medical decision making!

Thoughts?

 

[CodingKing]

Yes they can do that. It might be new to Highmark but there are other carriers that have required that for years. You can drop History or Exam but MDM was required. They don't have to follow CMS and can come up with their own guidelines. Just like sometimes CMS doesn't follow AMA guidelines.