Wiki MDM must be one of the 2 elements

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solocoder

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Our health system has recently created a new policy that says we must use MDM as one of the 2 elements considered in LOS for established patients. Soooo... that means that even when the doctor has recommended surgery to a patient he has been treating conservatively for a while, without much success, he can almost never get above a 99212? The one established, stable condition will bring them down to a 2 every time, no matter how good their history and exam are. Data points won't help. For elective surgeries they rarely review more than an xray or an MRI.
Am I looking at this right??
Or does the fact that they are recommending surgery mean the condition is not considered "stable"?
Any thoughts?
 
I think you make a very good point and I struggle with this too. The practice of requiring MDM to meet a level is becoming common, but in my opinion it's not a good policy for precisely the reason you describe, and because it also directly contradicts CPT. There are cases where a high level of history and exam are warranted and medically necessary but where MDM might not be as high - a provider may need to go through an extensive history and exam just to be able to say the patient is fine. I find that such a policy works best for highest level codes, but often breaks down as you move down toward lower codes. If you find the policy is requiring you to unfairly down-code provider claims, I'd recommend you take examples to your supervisors or managers and work with them to try to improve it.
 
solocoder said:
Our health system has recently created a new policy that says we must use MDM as one of the 2 elements considered in LOS for established patients. Soooo... that means that even when the doctor has recommended surgery to a patient he has been treating conservatively for a while, without much success, he can almost never get above a 99212? The one established, stable condition will bring them down to a 2 every time, no matter how good their history and exam are. Data points won't help. For elective surgeries they rarely review more than an xray or an MRI.
Am I looking at this right??
Or does the fact that they are recommending surgery mean the condition is not considered "stable"?
Any thoughts?
Click to expand...

I think you have answered your own question within your question - if "the doctor has recommended surgery to a patient he has been treating conservatively for a while, without much success" than that would be 2 points! The condition is not stable, otherwise he would not be taking him to surgery. Risk would be moderate to high, depending on the surgery and any co-morbidities. In that case your MDM could at least be low for at least a 99213.

I agree that making the MDM as one of the 2 elements is harsh. I worked for a company that used that theory too and I always felt it was inappropriately down coding. I feel this way of thinking is confusing "medical decision making" with "medical necessity" which are two different things and causes a lot of down coding of E/M charges. Actually, in the past I have had a couple charts randomly audited by a Medicare MAC - both coded as 99214 because the MDM was moderate - and both were corrected by the MAC to 99215 based on the comprehensive history and exam, even with the moderate MDM!
 
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