Pediatric Coding Alert

Surprise! CPT and CMS require medical necessity for all E/M visits

If you fall for the "E/M loophole" myth, you could miscode your E/M levels and collect thousands more in payment than you are entitled to receive.

Are there pitfalls in coding routine visits (ear infections, sore throats and so on) as level four (99214) instead of level three (99213), provided a physician meets the necessary coding guidelines? asked a pediatrician reader of Pediatric Coding Alert. "My partners have been exploring this as a way to increase revenue," he said. Let Medical Necessity Steer Code Choice The E/M guidelines absolutely do not offer physicians a legal "loophole" by allowing them to ignore medical necessity, says Stephen R. Levinson, MD, author of the AMA's Practical E/M: Documentation and Coding Solutions for Quality Health Care. "CMS indicates in its Carriers Manual that 'medical necessity is the overarching criterion for payment in addition to the individual requirements of a CPT code.' "

"The nature of the presenting problem is CPT's measure of medical necessity for E/M services," Levinson says. CPT includes this important contributory factor for every service level that measures care using the three key components.

Also: Physician specialty societies developed and approved CPT's Clinical Examples in Appendix C to illustrate the level of care representative patient problems warrant, Levinson says. The clinical examples "are provided to assist physicians in understanding the meaning of the descriptors and selecting the correct code," according to CPT. Realize 2 of 3 Creates 'Loophole' The loophole results from CPT's established patient office visit code descriptors. When reporting 99212-99215, you must meet or exceed two of the three elements for your level of service, says Janet McDiarmid, CMM, CPC, MPC, of St. Petersburg Pediatrics, which has eight offices serving Pinellas County, Fla. "For instance, if your history and examination was a 99214 and the medical decision-making was 99215, your code selection would be 99214."

So would it be appropriate to code 99214 when you take a detailed history and examination (99214) but your medical decision-making is of low complexity (99213)? "Anyone can document enough bullet points to qualify for a 99214 with regard to almost any complaint," says Charles Scott, MD, FAAP, pediatrician at Medford Pediatric and Adolescent Medicine in New Jersey. If you keep asking historical data and keep examining every body part, you will hit the criteria for the 99214 or even a 99215, he says.

Catch: There is a big overriding factor--medical necessity. "If medical necessity is not evident in the documentation, the charge could be downcoded and would be considered abusive behavior," says Suzan Hvizdash, BS, CPC, CPC-EMS, CPC-EDS, physician education specialist at UPMC Presbyterian-Shadyside in Pittsburgh. Count Relevant History, Exam  If you're still considering coding uninvolved otitis media [...]