Diagnosis, Alone, Doesn’t Justify a High-Level E/M

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  • July 15, 2015
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by John Verhovshek, MA, CPC
Follow-up visits with critically (or terminally) ill patients won’t necessarily call for a high-level E/M service. For example, when a patient is in the middle of chemotherapy, and no adverse reactions are reported or no new complaints are noted, the visit would not merit a high level just because there is a cancer diagnosis.
The number one requirement driving any medical service is always medical necessity. Medicare’s Claims Processing Manual, Chapter 12, 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. 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.

CMS specifically allows providing the status of chronic illnesses as an alternative method to describe the history of the presenting problem. To count as HPI (history of present illness), the name of the illness must be stated, along with the status of the illness, and a description of the treatment plan. Be sure the provider documents his or her decision-making processes by listing any possible concerns regarding the status of multiple chronic conditions. This will provide clarity in supporting medical necessity for higher-level services.

Evaluation and Management – CEMC

John Verhovshek
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About Has 575 Posts

John Verhovshek, MA, CPC, is a contributing editor at AAPC. He has been covering medical coding and billing, healthcare policy, and the business of medicine since 1999. He is an alumnus of York College of Pennsylvania and Clemson University.

No Responses to “Diagnosis, Alone, Doesn’t Justify a High-Level E/M”

  1. Charles Drake 01332003 says:

    Thanks for the comments on the modifiers. They were not covered well when I was taking classes, and the CPT is not always clear. I will be checking for new posts.
    Sincere regards, Charles