I have been coding for about six months now and I recently received some feedback on an official audit that was done on a couple of my providers. It was noted on the report, for example, that for established patients if the history and exam portions of the visit met a 99214, but the medical decision making of the same visit met a 99213, the visit should have been coded as a 99213.

I’m wondering if the accepted practice is to now always use the MDM plus either the history or exam portions to determine your E/M level when only 2 out of the 3 components are required? Or are you using just the history and exam portions in order to code at the highest level possible?

We are going to be having a discussion about this topic at work in a few days, so I’m interested in hearing what methods other coders are using. Thanks in advance!