Coding, Classification and Reimbursement

MDM as one of the E/M leveling elements

  • 1.  MDM as one of the E/M leveling elements

    Posted 12-31-2018 17:07
    Hi, I have a question for those of you coding Orthopedic or other specialty type clinics. Do you use MDM as one of the leveling elements when determining your E/M code on follow-up joint patients or follow-up fracture patients that are beyond the global period? I'm looking at over a year out, but continue to be monitored by the provider?

    Below is some guidance we were given recently and are wondering if others follow this same concept? It would surely affect the reimbursement on these follow-up visits if we follow this direction. As you will note, the guidance is stating that if an x-ray is performed at this visit and the patient is stable, you wouldn't count this data element. Are others practicing this way currently?

    • Using the medical decision making component for established patient visits may more accurately reflect the medical necessity of the service.

    o Reasoning: EMR's templating is often set-up to prompt the provider into a high level of history and exam - even for relatively minor problems. Although providers may include any and all data that they deem appropriate in their patient's notes, they are required to bill only for the elements that are medically reasonable and necessary for the treatment of the patient.

    • By requiring medical decision making to be used as one of the 2 components for code leveling of established patient visits, the medical decision making can be used as a barometer for the medical necessity of each encounter.

    How does this affect reimbursement?
    Visits in which the patient is following up to one established, stable condition, with only 0-1 data points, would qualify for 99212 - whether or not the history and exam are documented at higher levels.
    Examples:
    • visit for a stable fracture
    • a follow-up visit to surveillance of an arthroplasty in which patient is doing well with no issues
    • a follow-up visit after injection/procedure in which patient is doing well.

    In other words, visits that previously qualified for 99214/99213 based on the history and exam components would be coded to 99212 based on the medical decision making of the visit. This would result in a reduction of revenue for encounters fitting this scenario. However, not using the MDM for established patient visits could flag insurance contractors due to a pattern of higher level visits in which paybacks may be determined.

    Thank you,
    Diana

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    Diana Cupp
    Coding Supervisor
    Sauk Prairie Healthcare
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  • 2.  RE: MDM as one of the E/M leveling elements

    Posted 01-09-2019 20:14
    Where did you receive this guidance from? The CPT requirements for E/M levels must meet all the criteria in order to be chosen which for established patients means 2 of the 3 components. I dont think it would be correct to only look at MDM to choose your levels.

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    Sarah Moden, RHIA, CCS-P
    Medical Coder/Trauma Registrar
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  • 3.  RE: MDM as one of the E/M leveling elements

    Posted 01-10-2019 09:48
    ​Hi Sarah,

    This was given to us by an external auditor we had review our clinic charts. I know I have also listened to many webinars where they are stating that MDM should be 1 of the 2/3 elements when determining the level. I believe the rationale is because medical necessity is the overarching criterion so this goes hand in hand with MDM.

    Do you have a different information to offer?

    Thanks,
    Diana

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    Diana Cupp
    Coding Supervisor
    Sauk Prairie Healthcare
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  • 4.  RE: MDM as one of the E/M leveling elements

    Posted 01-10-2019 11:58
    I have always used the MDM for 1 of the elements and trained the providers to do likewise.  I don't think there is anything documented for using MDM as one of the 2 elements, however, the visit must be medically necessary for payment.  If only using HPI and Examination to meet the 2 elements, then this is based only on documentation.  You could get the complex level in both areas based only on documentation which would result in a high level.   However, if the MDM is low, then there would be a question of medically necessary for the high level charge.  This is just my thoughts.  Any other rationale out there?

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    Nelda Laskey RHIT
    Coder/RAC Coordinator
    Kearny County Hospital
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  • 5.  RE: MDM as one of the E/M leveling elements

    Posted 01-10-2019 12:35
    ​Thank you Nelda. Your explanation makes sense and very wise to educate your providers to document in this fashion as well.

    Have a wonderful day,
    Diana

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    Diana Cupp
    Coding Supervisor
    Sauk Prairie Healthcare
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  • 6.  RE: MDM as one of the E/M leveling elements

    Posted 01-11-2019 16:17
    Note that some of the MACs provide further guidance on their requirements/recommendations for determine E/M services.  Several indicate that the medical necessity of the service must support the E/M which will come from the MDM.

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    Carine Leslie, RHIA, CCS, AHIMA-Approved ICD-10-CM/PCS Trainer
    Senior Consultant
    Pershing Yoakley & Associates (PYA)
    cleslie@pyapc.com
    404-266-9876
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