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meganpoelzer

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Hi,

Our practice has been using an EMR since 2004, but we recently upgraded to a newer version. The E/M calculator now follows Alpha II (coding software) standards.

For an established patient, MDM must be 1 of the top 2 out of 3 elements. I don't necessarily agree that the MDM always represents the medical necessity, but that's how this computerized E/M calculator works.

Does anyone know if the MDM having to be 1 of 2 elements is becoming an industry standard? As far as I understand, as long as (any) 2 of 3 elements meet a level, you are coding correctly, assuming documentation follows the medical necessity of the problem.

Thanks,

Megan B, CPC
 
MDM as 1 of 2 in choice for level of service

Everything I've read, everyone I've heard speak to this subject has either said outright, or strongly implied that your MDM needs to be one of the two elements in an established patient choice of codes. This has been pretty much the standard since the '95 guidelines came out.
 
Carol,
Thanks for your response. I would be interested to hear where you have read that says MDM needs to be 1 of 2 key components. I've heard the same, but how can this be if it's not specifically stated by Medicare or CPT?

The only thing I could find in the 1997 guidelines specifically related to selecting a level states "While some of the text of CPT has been repeated in this publication, the reader should refer to CPT for the complete descriptors for E/M services and instructions for selecting a level of service."

CPT doesn't say anything other than "...requires 2 of 3 key components: hx, exam, MDM". It's my feeling that as long as your hx and exam are being documented appropriately based on the medical necessity, why can't hx and exam be the 2 of 3 key components?

I think alot of money could be lost if every visit gets downcoded because the MDM is not as high as hx and exam (as long as the hx and exam are appropriate for the presenting problem).

Megan, CPC
 
This statement that can be found in Pub. 100-04 Medicare Claims Processing Manual, here is the link http://www.cms.hhs.gov/transmittals/downloads/R178CP.pdf

Medical necessity of a service is the overarching criterion for payment in addition to the individual requirements of a CPT code. It would not be medically necessary or appropriate to bill a higher level of evaluation and management service when a lower level of service is warranted. The volume of documentation should not be the primary influence upon which a specific level of service is billed. Documentation should support the level of service reported. The service should be documented during, or as soon as practicable after it is provided in order to maintain an accurate medical record.

Many have interpreted this statement to mean that the MDM is synonymous with Medical Necessity and therefore it must be one of the 2 components used. Just speaking from my own experience, the EMR makes it very easy for a physician to over-document if they haven't received the proper training in E/M prior to using an EMR.
 
Thank you Angela. I agree that EMRs do make it easy for providers to overdocument. That's why we have to educate them! Your information was very helpful.

Megan, CPC
 
The way I know it is that the MDM is the driving force when arriving at the level, but there are exceptions in which it might be appropriate to bill a higher level based on history and exam, for example you have a medically necessary detailed history, a medically necessary complete exam, but your MDM overall comes out to low (1 worsening problem, high risk drugs, no data). In such a case the higher level should be OK even though the MDM is low.

Let's say you have a patient with lung Cancer, just by describing the CA you have 4 HPI elements. You ask the patient about fevers and breathing - this gives you 2 ROS (constitutional and respiratory). The patient reveals s/he finally quit smoking (this is pertinent social hx - at the prior visit s/he still smoked and had a hard time giving it up) - there is your detailed history.
The physician conducts a thorough exam - either detailed or complete.
History and exam so far allow a level 4 established - but there is no MDM yet.
Now, this CA is slowly progressive (= worsening problem, 2 points in part A, diagnoses); the provider orders a scan to assess the progression (1 point in part B, data); the patient is on a highly toxic chemotherapy regimen because otherwise the CA would get out of control (high risk) - despite the severity of the situation the MDM is "only" low.
In such a situation I would allow the higher code based on hx and exam.

It is true that MDM should be one of the top two, but it is nowhere stated that there are no exceptions.

As for the coding software - take it with a grain of salt. It is only as good as the person/team that programmed it and coding has so many nuances, the software cannot catch everything. This is one area where the human brain still has the edge.

That my take on it....
Karolina, CPC
 
I was just getting to ready to respond with the same information and rational as Karolina. That is exactly how I explain it so way to go!
 
Thank you very much to everybody that responded. It was bothersome to me that the coding software would always code it this way, and I wanted to make sure it wasn't an industry standard. Thanks again!!
 
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