Why Medical Decision-Making Is the Best Predictor of E/M Service Level
Medicare’s Claims Processing Manual, section 30.6.1.A, stipulates, “Medical necessity of a service is the overarching criterion for payment in addition to the individual requirements of a CPT code.” But in the everyday struggle to assign E/M codes, medical decision-making (MDM) is usually the best indicator of the E/M service level.
When two of three components (history, exam, or MDM) are necessary to support the level of service, CPT® does not require that MDM must be one of those elements; but, the wise coder will proceed with caution if the levels of history and exam exceed the level of MDM. The history and exam should approximate the level of MDM because MDM influences the extent of history and exam that are required.
Additionally, the use of templates can make it too easy for a provider to document more detail in the history and exam than is necessary, which can lead to upcoding. As the Claims Processing Manual clarifies, “It would not be medically necessary or appropriate to bill a higher level of evaluation and management service when a lower level of service is warranted. The volume of documentation should not be the primary influence upon which a specific level of service is billed.”
You cannot rely exclusively on MDM to determine the level of service, however. For example, when the E/M code requires three of three components to qualify for a given level of service, the lowest component (whether history, exam, or MDM) always determines code selection.
The bottom line: You must consider the entire E/M service, as documented. MDM is a good guide to the overall E/M level, but by itself if can determine nothing. Medical necessity remains the overarching criteria for all services.