Follow-up visits 99212-99215

Hello all- Happy New year!

When I am auditing a follow-up visit (99212-99215), I audit the entire note, History, Exam and MDM. I know for the follow-up visits you only need 2 out of 3 element to pick your level so I have some docs that will hit a level 99215 every note with the history and exam alone, so my question is, with the 2 out of 3 rule, do I have to factor in the MDM or can I stop after the exam if I have a 99215??

Should I be taking into consideration that a pt coming in for sick call because of n/v from chemo with MDM with a high level and a complete history and exam is 100% a 99215 because of the severity but someone that comes in for stable anemia and they only request bloodwork isn't even though the history and exam meet the requirements for a 99215, would I have to change this to a 99213 because of the low MDM?

Mdm

Established patient codes require 2 of 3 key components. MDM is used by many payers as the driver for accurate code selection. If you discount MDM in your audits, the H&P may be billed at level 5 but the MDM was low complexity (example only). This would lead to the question of why a comprehensive H&P was performed when the decision making was low. This would be caught in a payer audit. On the other hand, assuming that the medical decision making qualifies as being of moderate complexity and that medical necessity is clear, documenting either a detailed history or a detailed exam will support coding 99214. Medical necessity is the over-riding issue and common sense.

The rule is...

that the "Complexity of the presenting problem is the overriding factor in determining the level of care"- this has been repeated by CMS in several places (none of which I have available) but it is clear that with an EMR you can make every level a 5 with the 2 of 3 rule. Common sense rules again!