Wiki Interpreting the 2 out of 3 E&M coding guidelines

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plarabee

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We are having a discussion here in the auditing department on whether or not an exam is required for a follow up exam. I quote "Two of the three key components (i.e. history, exam and medical decision making) must meet or exceed the stated requirements to qualify for a particular level of E/M services.." I interpret that to mean you only need to document 2 of the 3 components. However, a few others interpret it to mean that you still need to document all 3 but choose the level based on the highest two I have been researching all morning and cannot locate anything that supports one interpretation over the other. I would love to get feedback regarding your interpretations. Thanks.

Pat Larabee, CPC
 
You only need two out of the three for your subsequent visits or established visits in the office. I hear they are looking into to changing the evaluation and management guidelines. I hope they do.
Sheila
 
This question has come up and been debated a number of times on this forum and if you'll do a search you will find a wide variety of opinions on this. In my own opinion, after quite a bit of experience internal and external E&M audits, since CPT guidelines do not state anywhere that all three components must be documented, there is no such coding requirement. However, many coders rightfully point out that the omission of one of these key elements in many cases can pose a potentially serious documentation quality issue, so there are coders who feel that there must be at least some element of each of the three components. Since the question is not explicitly addressed in any official guidelines that I am aware of, it falls into that broad category of a coding 'grey area' and is something you and your organization will have to decide how to answer. Certainly the safest approach is to have all three elements present. There very little effort required on the provider's part to document at least one component of each element, for example the patient's general appearance or vital signs for the exam, and this would give you an added protection of avoiding a problem with an unfriendly auditor who might see things differently.
 
Per CMS-Medical necessity is the overarching criterion to select code level. it wouldn't be appropriate to bill a 99215 for a cough right? Provider could have Comprehensive History and Exam. Therefore rule of thumb I use is MDM must be one of the 2 for EM selection. You will find no exact language indicating which 2 should count. This is when we need to use our medical coding critical thinking skills! The only guidance I have from our local MAC is provided on link below:

https://www.novitas-solutions.com/w...ntentId=00099545&_adf.ctrl-state=pshrvkk6s_30
 
This is such a huge debate and I am having a time where I'm at. So where did you find the language that CMS says to use MDM as the criteria. I need something in writing to defend this?
 
gchmelewski said:
This is such a huge debate and I am having a time where I'm at. So where did you find the language that CMS says to use MDM as the criteria. I need something in writing to defend this?
Click to expand...

There is no CMS language that says MDM must be used. The CMS guidance that is most frequently cited is from Chapter 12 of the Medicare Claims Processing Manual, section 30.6.1 - Selection of Level of Evaluation and Management Service, where it states "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." You will find many articles that discuss this, and it is important to understand that medical necessity and MDM are not the same thing.

Some practices and coders use MDM as a guide to determine medical necessity, and may require MDM to be one of the two criteria for an E&M level in order to avoid billing excessively high levels of E&M codes when providers over-document the history and exam sections of their notes. However, this is not a requirement by CMS. I have heard that some specific payers have policies to this effect, but it is not a standard coding rule. In my experience, this practice is unreliable and can lead to incorrect coding, and I do not recommend it.
 
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