Wiki MDM vs Medical Necessity

[amexnikki23]

Im hearing mix reviews on discussions regarding meeting MDM but not necessarily meeting medical necessity. Example, the "myth" that is covered in the MDM or Medical Necessity upcoming workshop which states "just because there are 3 chronic condition does not automatically make it a 99214."

What might be a case where the evaluation and management of 3 chronic conditions (say, stable DM, stable HTN, and stable hyperlipidemia w/Rx refills) does not meet the medical necessity of a level 4? We add up the problem points, data reviewed and risk, and always come up with a 99214. Just looking for some examples of when this may not be the case, with respect to medical necessity. Thanks!

 

[thomas7331]

You are correct that documented evaluation and management of 3 chronic condition does always work up to moderate MDM, but of course, that alone is not enough since you also need the required second component of history or exam of course to support a 99214.

But I think the 'myth' that is being referred to is that MDM equates to medical necessity. We've seen coding audits that suggest that if MDM is straightforward or low, that a 99214 is not medically necessary and I believe that is incorrect and is the point here. Depending on the nature of the presenting problem, a more extensive history and exam might be required to arrive at an assessment and plan which does not involve complex MDM, so a 99214 might still be appropriate. I'm planning to attend the workshop though and look forward to hearing more on the topic.

 

[amexnikki23]

I plan on attending as well. My employer counts MDM for all est. patient visits, and then we pick or choose the H or E component. But in looking back to EM training before the real world, as well as the CPT guidelines, any 2 out of 3 components are acceptable. Thanks!