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Question: One of our providers saw a Medicare beneficiary who visited for a problem that our provider couldn’t effectively treat. Our provider referred the patient to a specialist. Can we count their decision to refer the patient as medical decision making (MDM)?

Hawaii Subscriber

Answer: According to Medicare Administrative Contractor (MAC) CSG, a clinician is addressing or managing a patient problem when evaluating or treating the patient accordingly during an encounter. If the patient’s medical record has documentation saying that a different practitioner is treating the patient, without further assessment or care coordination, then the initial clinician can’t put the effort toward MDM, per evaluation and management (E/M) guidelines.

A referral encounter without evaluation, which includes history, exam, diagnostic study, or consideration of treatment, is a visit that doesn’t involve any conditions addressed or managed. In order to level an encounter for E/M and potentially receive reimbursement from Medicare, a provider would need to address the problem and then account for the level of the problem, the amount and complexity of data, and the risk to the patient to select the correct category of MDM. In this situation, your practice’s provider passed those responsibilities onto the provider to whom they referred the patient.

Rachel Dorrell, MA, MS, CPC-A, CPPM, Development Editor, AAPC