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Choosing a level using 2 out of 3 or using MDM as determining factor

David Posted Thu 25th of August, 2016 13:41:22 PM
I have a question. I started coding about 2 years ago. When I was trained by another coder they trained us to choose a level of service based off having 2 out of 3. Example: History - Expanded Problem Focused Exam - Expanded Problem Focused MDM - Problem focused So the person training stated because 2 of the 3 met a level 3 for an established patient that is what we use. However after that person left and I gained more experience I started to see a lot more about coding making the level of service based off of the MDM. So in the example above using those guidelines I now would code this as a level 2 (99212). Just wondering what the best practice is and if we are looking at this the right way now coding the level based off of MDM as we now do. Thank you
SuperCoder Answered Fri 26th of August, 2016 09:19:15 AM


2/3 criteria means that any 2 out 3 component (e.g, History, Exam and MDM)  should meet at same level to find out the final code from a given set of code series. Services are reported based on meeting two of the three key components: history, exam and medical decision making (MDM) within each level of service. Please check with the insurance company as some payers consider MDM as key component for 2/3 criteria as they need medical neccesity to process the claim.

If a patient following provider since 3 months for certain cancer chemotherapy. The provider document an appropriate expanded problem focused history, and an expanded problem focused examination, but the MDM is straightforward and cancer is stable. If we code this report entirely on MDM, we would find a 99212. In this scenario, if there is medical necessity for a expanded problem focused history and expanded problem focused exam to find conclusion of the diagnosis, then a 99212 would not be appropriate. Also, same with the exmple mentioned in the question.

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