Part B Insider (Multispecialty) Coding Alert

Published on Fri Dec 14, 2012 PDF

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?

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 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, but indefensible and inconsistent with medical necessity for the service provided.

Caution: Remember that medical decision making is not the same as medical necessity. The patient may be told to go home with no further treatment, but that doesn’t negate all the decision-making that went into that determination. Thus, the two are not the same. MDM does not have to be one of the two elements in determining the established patient’s code.