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MDM vs Medical Necessity

Jamie Posted Tue 09th of April, 2019 17:03:28 PM
Per the below scenario our providers are coding a 99213 but when auditing the records using 1995 guidelines we get History -99213, Exam-99213, and for MDM -99212... which makes this visit level qualify for 99212 as mdm controls the level of the visit. Our providers are coding 99213...Stating that medical necessity should be considered due to the moderate risk of controlled substance being prescribed. What would be considered the appropriate level of service for the below scenerio: Chief Complaint: 29 yo male here for adderall med rf History of Present Illness: Patient presents for follow up on ADD. He takes Adderall long acting and short acting daily for good control of his symptoms without any unwanted side effects. Review of Systems: No sleeping issue. Mood is good.No palpitations Past Medical History: Medical Problems: Asthma, ADD - neuropsych eval 5/13 Medications: 1) Adderall 20 mg oral tablet, 1 tab po daily in afternoon Physical Examination: Wt: 187.4 lb Ht/Ln: 72 in BMI: 25.4 BP: 137/87 Pulse: 101 RR: 18 Temp: 97.8F Sat: 97 GENERAL: WNWD NAD LUNGS: Clear to auscultation without wheezes. HEART: RRR without murmers, thrills, rubs Assessment & Plan: # Attention deficit disorder (F90.0): PRESCRIBE: Adderall XR 20 mg oral capsule, extended release, 1 tab po qam, # 30 , RF: 0. PRESCRIBE: Adderall 20 mg oral tablet, 1 tab po daily in afternoon, # 30 , RF: 0. AKPDMP is reviewed
SuperCoder Answered Wed 10th of April, 2019 07:54:39 AM

Hi Jamie,

The appropriate level of the service for the below scenario will be CPT 99213.


The above scenario has expanded problem focus (EPF) History, expanded problem focus (EPF) Examination and Low medical decision making, which makes it to be 99213. (as per the guidelines for established patient 2/3 rule follows- or we can say “drop the lowest and pick the lowest”). Hope it helps.

Jamie Posted Thu 11th of April, 2019 19:30:41 PM
When determining just the level of MDM, please clarify how this MDM qualifies as Low medical decision making. We are getting Straightforward MDM, per the # of DX, 1 stable illness equal to 1 point, and the risk is low for a chronic stable illness. We do not meet or exceed Low medical decision making with at least two elements of MDM, when considering the data (1) and risk (low).
SuperCoder Answered Fri 12th of April, 2019 09:03:03 AM

Hi Jamie,

You are correct, we are getting MDM as straightforward. But, it will not make any change in our E/M level based on history and physical examination. Our code 99213 remains the same for the above scenario as per general rule.

However, check with your provider, if MDM is required by the payer then the level of E/M will be 99212. Please feel free to ask for any further query.

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