Primary Care Coding Alert

Surprise! CPT and CMS require medical necessity for all E/M visits If you are a victim of the -E/M loophole- myth, you could be severely miscoding your E/M levels and collecting thousands more in payment than you are entitled to collect.

A physician recently wrote to Family Practice Coding Alert with the following comment: -The rules as I interpret them say that I can bill a level 99215 based on history and examination if I can substantiate in the record that I performed a comprehensive history and examination on this patient, even though the medical decision-making is low risk and there is no data to review ... Nowhere does it say I must -justify- the code after meeting the criteria.-

Therefore, the physician feels she is entitled to bill 99215 for any E/M visits during which she performs a comprehensive history and exam, even if she simply treats a runny nose.

So the question is: Do the E/M guidelines offer physicians a legal -loophole- by allowing them to ignore medical necessity?

-Absolutely not,- 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, -and this important contributory factor is included for every level of every type of service that measures care using the three key components. Additionally, the Clinical Examples in Appendix C of CPT have been developed and approved by our own specialty societies to illustrate the level of care warranted by representative patient problems, and CPT directly tells us that the clinical examples -are provided to assist physicians in understanding the meaning of the descriptors and selecting the correct code.- -

Explore the Origins of This -Loophole- Some coders may wonder why their family physicians try to use what they consider to be a loophole. -It's not really a loophole as much as it is a code definition,- says Suzan Hvizdash, BS, CPC, CPC-EMS, CPC-EDS, physician education specialist for the department of surgery UPMC Presbyterian-Shadyside in Pittsburgh. -In CPT it says that on established patients, only two out of the three components need to be met in order to code the service. However, there is a big overriding factor -- medical necessity.

-If medical necessity is not evident in the documentation,- Hvizdash says, -the charge could be downcoded and would be considered abusive behavior.-

In addition, you should consider the amount of time that CPT suggests for billing 99214 or 99215. CPT states that these codes normally require 25 and 40 minutes of [...]