Gastroenterology Coding Alert

Question: Our physician is an amazing documenter — for established patients (which only require two of the three elements required for a particular E/M code), he almost always qualifies for 99215 even if he’s just doing a medication refill. He wants to know what should be the main factor he should use to select the overall level of service for an E/M service.

New York Subscriber

Answer: Medical necessity should always be the overarching factor used to select the E/M service level, which CMS has reiterated several times, including in Transmittal 178 (http://www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/downloads/r178cp.pdf). Just because a physician completes a comprehensive history and examination doesn’t mean he should always report a level-five code. Medical necessity should always drive the components that he performs. Practices that try to exploit this loophole could be severely miscoding E/M levels.

This mindset is particularly worrisome with the implementation of EHR systems, which often automatically code encounters without regard to medical necessity. It is very easy to document high levels of history and exams, particularly for established patients, which will result in level four and five services when the medical necessity may dictate only level two or three services. This constitutes "electronic upcoding," which is defensible based on history and physical key elements, but indefensible and inconsistent with medical necessity for the service provided. However only the provider can determine (and support in the documentation) that the intensity of the E/M service met and did not exceed the patient’s clinical needs.

Caution: Coders and clinicians should recognize that vital information about the patient’s condition necessary in determining medical necessity of the encounter is usually located in the Medical Decision Making section of the record. The recorded MDM should portray the physician’s thought evolution about the patient, synthesizing documented history and physical examination information into diagnostic impressions and treatment plans. Because of this unique dependence on the information contained in the MDM component, even though a medical record might contain a perfectly complete history and examination, without a correspondingly complex MDM there may be no justification for payment of a high-level E/M service. In fact, without adequate record of physician impressions and planned diagnostic/therapeutic intervention, the encounter might be rendered of no clinical benefit at all and not payable at any level.

Overlooking the documentation of your thoughts can sabotage an otherwise good clinical record. It can make the difference between an encounter portrayed on paper as an over-documented simple visit versus a complex clinical problem that the physician failed to adequately address.