General Surgery Coding Alert

Question: I-m not clear on what CPT intends when it states I may report a given E/M level if the physician documents "at least two of these three key components." Does that mean that if the surgeon always documents a comprehensive history and exam, for instance, that I can report 99215 for every established patient visit?

Nevada Subscriber

Answer: When an E/M code descriptor says a code "requires at least two of these three key components," you can drop the lowest element and use the other two elements to select the appropriate E/M service level.

Quick example: The surgeon documents a detailed history, a comprehensive exam, and high-complexity medical decision-making (MDM) for an established patient visit. In this case, you can eliminate the lowest element (the detailed history) and allow the remaining two elements to justify reporting 99215 (Office or other outpatient visit for the E/M of an established patient, which requires at least two of these three key components: a comprehensive history, a comprehensive examination, medical decision-making of high complexity -).

There's a catch: If the presenting problem won't support a high-level E/M service, you can't get paid for the service just because the physician documented a comprehensive history and exam. Medical necessity is the overriding factor that should determine the service level.

For example, you could not justify a 99215 claim for a patient who presents with an obviously benign lesion. In this case, a detailed history and exam are overkill and not supported by medical necessity.

When an E/M code descriptor instead instructs that you must meet all three key components, to select a given service level, the lowest element (history, exam or MDM) becomes the determining factor for your code selection.

Quick example: The surgeon provides an outpatient consultation and documents a detailed history, a comprehensive exam and high-complexity MDM. In this case, the lowest element (the detailed history) dictates that you report 99243 (Office consultation for a new or established patient, which requires these three key components: a detailed history, a detailed examination, and medical decision-making of low complexity -).

Typically, new patients or initial visits require all three components, and established or subsequent visits require just two -- but don't make assumptions. Check the code descriptor to learn how many elements you-ll need to support your E/M code choice.