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tmerickson

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So fellow coders...
In the AAPC October Healthcare Business Monthly, there was an article about the difference between choosing the E/M code from MDM or medically necessity. Maybe I misunderstood the article, but basically it said, if it's "medically necessary" you can bill a 99215 for a patient with a cold. In my own words, of course.

Then, the test question is "If the H=99213, E=99213 but MDM=99212, CMS says the code will be 99213".

So, I want to hear your thoughts and opinions on this-I'm interested in if you have the same thoughts about this article and test answer that I did. Because, seriously, I have alarms going off in my head. :eek:
 
I'm not interpreting the article the same way as you are. Its really talking about how existing patient only needs to meet 2 of 3 components. Say MDM is level 1 but History and Exam is level 5 you can bill a level 5. However, Comprehensive History and Exam must still be medically necessary based on the presenting problem.

I hate when my PCP does Comprehensive History and Exam when i'm only in there for a tennis elbow injection just so he can bump up the E&M level.
 
Since MDM is not the same as Medical necessity, there are times that MDM will not trump the other key components and drive the code and that medical necessity will allow you to report based on the other two key components.

For example: patient comes in for 6 month follow up of breast cancer. No known evidence of disease, chemo/radiation is completed, no symptomology. Patient may be on Tamoxifen. In order for the provider to determine that the patient is stable, she does a detailed history, detailed exam. The patient is stable and would meet a straightforward MDM. However, the work done in the history and exam was medically necessary in order to draw that conclusion. In instances like this, we sometimes "split the difference" and bill a 99213 instead of the 99214 (based on history and exam) or 99212 (based entirely on MDM).

Counting those bullets is important when the nature of the presenting problem mirrors the documentation provided, but there are times that following the audit tool and factoring LOS based entirely on number of systems documented and components met, may not meet medical necessity. This is one of those very gray areas of coding, and payers just don't have guidance around the many scenarios that could take place.
 
CodingKing said:
I'm not interpreting the article the same way as you are. Its really talking about how existing patient only needs to meet 2 of 3 components. Say MDM is level 1 but History and Exam is level 5 you can bill a level 5. However, Comprehensive History and Exam must still be medically necessary based on the presenting problem.

I hate when my PCP does Comprehensive History and Exam when i'm only in there for a tennis elbow injection just so he can bump up the E&M level.
Click to expand...

This is definitely not supported and if audited your doctor will lose. You CANNOT do a Level 5 History and Exam for the condition you describe and bill a 99215. I have been involved in MANY audits and if your provider is doing that, they will certainly catch up with him/her. Especially if they do it too often. They will then receive the dreaded "potential aberrancy in your billing patterns" "compared to those of your peers" letter.

Not to mention, there needs to be a separate reason for him to E/M you if you are in just for an injection.

Are you just testing us?
 
suemt said:
This is definitely not supported and if audited your doctor will lose. You CANNOT do a Level 5 History and Exam for the condition you describe and bill a 99215. I have been involved in MANY audits and if your provider is doing that, they will certainly catch up with him/her. Especially if they do it too often. They will then receive the dreaded "potential aberrancy in your billing patterns" "compared to those of your peers" letter.

Not to mention, there needs to be a separate reason for him to E/M you if you are in just for an injection.

Are you just testing us?
Click to expand...

Not testing you. I know they cant. If you do a comprehensive exam and the presenting problem only warrants a problem focused exam you cant count the exam any higher. I was looking at the comment above about a physician thinking they could try to get a 99215 out of a common cold, it would be next to impossible.
 
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