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Is medical decision making a trump card in E/M services?

March 29th, 2009 - Codapedia Editor
Categories:   Coding   Documentation Guidelines   Evaluation & Management (E/M)  
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Physicians who treat patients with very serious illnesses sometimes think that they can select the highest level of service in any category based on the high acuity of the patient.  After all, isn't a patient with a brain cancer really sick?  Shouldn't that patient always be charged a high level visit?

No.  Medical complexity is not a trump card in selecting an Evaluation and Management service.  If the medical decision making is high, according to the Guidelines, the physician must still document the history and exam (for 3 of 3 codes) or the history or exam (for 2 of 3 codes) in order to bill a high level visit.  Also, the way the guidelines are written, for follow up services, sometimes these very sick patients do not meet the criteria for a high level visit. MDM is based on meeting the requirements in two out of three of these components: the number of diagnoses/treatments, amount of data, and table of risk.  Often, the patient has one worsening problem, two or three data elements and then high complexity from the table of risk.  This MDM does not allow the highest level of service.

Oncologists (and all other clinicians who deal with one, very serious problem) need to review the guidelines carefully when billing the highest level of service.  Don't assume that the visit warrants the highest level.  Consider whether using time to select the code is relevant to the patient visit.

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