Medicare Compliance & Reimbursement

Question: What should be the overarching factor you use to select the overall level of service for an E/M service? Answer: Medical necessity should always be the overarching factor used to select the E/M service level. Just because a physician completes a comprehensive history and examination doesn’t always mean he should 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, [...]