When selecting an E/M service for an established patient, does medical decision making need to be one of the determining factors?
This answer relates to E/M services 99211–99215, and is relevant until Dec. 31, 2020. Then, it is superseded by the CPT E/M definitions.
Not according to CMS. Recently, when I was explaining the two of three rule to a physician, he said, “Just like the Meatloaf song.” I hadn’t ever considered Meatloaf and the Documentation Guidelines together.
Medical necessity and the nature of the presenting problem need to be considered when selecting a level of E/M service. The volume of information in our electronic health records has multiplied like bunnies. Coders are often reasonably reluctant to credit higher level visits.
Often the documentation is voluminous but the physician/NP/PA has selected a lower level code. If a clinician seems to be either overdocumenting or cloning notes, this is a situation to be discussed with the medical director and practice manager.
But, there are often situations in which a clinician needs to perform a higher level of history and exam, in order to diagnosis a condition. For example, a patient with chest pain, even if the plan is “take an OTC medication” needs an assessment before that is decided.
And, consider an Infectious Disease specialist who is taking care of a patient with one, serious chronic problem. If that problem is in good control, which we hope it is, requiring MDM to be one of the components would undervalue the work and the level of service.
- Everyday Coding includes a comprehensive list of articles on E/M Services
- Medical Decision Making
- Three Key Components of E/M Services
- E/M Cheat Sheet
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