Pulmonology Coding Alert

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 deserve -- and that could lead to dire consequences down the line.
 
MDM Matters Most, CMS Says
 
The argument: Some physicians and coders reason that CPT guidelines allow reporting 99215 for an established patient based on a "comprehensive" history and a "comprehensive" examination, even if the medical decision-making (MDM) is low risk and there is no data to review. 

Therefore, the argument goes, you may report 99215 for any E/M visits during which the physician documents a comprehensive physical and exam, even if the physician treats a minor problem. 

The big question: Do the CPT E/M guidelines offer physicians a legal "loophole" by allowing them to ignore medical necessity?

The answer: "Absolutely not," says Stephen R. Levinson, MD, author of the AMA's Practical E/M: Documentation and Coding Solutions for Quality Health Care. CMS guidelines explicitly state, "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 anapproved 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 guide physicians in understanding the descriptors' meanings and selecting the correct code.

"CPT says that for established patients, only two out of the three components need to be met to code the service. However, there is a big overriding factor -- medical necessity," says Suzan Hvizdash, BS, CPC, CPC-EMS, CPC-EDS, physician education specialist for the department of surgery UPMC Presbyterian-Shadyside in Pittsburgh.

"If medical necessity is not evident in the documentation, the charge could be downcoded," Hvizdash says. This could cause the insurer to request a repayment.
 
History Must Be Relevant
 
If your pulmonologist still balks at coding simple, uninvolved visits using 99212 or 99213, refer him to the E/M documentation guidelines, which make several references to medical necessity, says Erica D. Schwalm, CPC-GSS, CMRS, billing and coding educator in Springfield, Mass. Schwalm refers to the following references from the 1995 E/M guidelines:

1. Must have: "The documentation of each patient encounter should include: reason for the encounter and relevant history, physical examination findings and prior diagnostic test results."

The key word here is "relevant‚" Schwalm says. "If the patient presented with a runny nose, a comprehensive history and exam would not be relevant to the reason for the encounter," unless documentation also includes the list of suspected differential diagnoses that warrant intense investigation.

2. Rely on presenting problem: "The extent of examinations performed and documented is dependent upon clinical judgment and the nature of the presenting problem(s)," states CMS in the "1995 Documentation Guidelines for Evaluation & Management Services."

The clear message here is that the history and examination that the physician performs should correlate with the presenting problem(s), Schwalm says. Medical decision-making can help to support the extent of the history and exam that the physician obtains if he conscientiously documents his efforts and cognitive process.
 
Insurers Look at Bell Curves
 
Remember that an auditor will look at any billed E/M services against the medical necessity, so your documentation will have to speak for itself.

And an unusually high number of upper-level services will almost surely draw your payers' attention. If your physician bills all 99214s and 99215s, you could set off a red flag to your insurer, which could in the long run also hurt your bottom line, Schwalm says.

Local carriers use "bell curves‚ or utilization data by specialty, to target practices for audits," Schwalm says. "If you start billing out a majority of your E/M services at higher levels, your utilization data will be well above what is considered the norm, which could make you a target for an audit." But if the services are reasonable and necessary, and the documentation accurately reflects the services provided, the physician can pass an audit.

Do this: If your pulmonologist tries to code to the "loophole," you should show him CPT's clinical examples of which visits warrant which E/M codes (found in CPT's Appendix C). Also, show him the E/M guidelines that refer to providing medically reasonable and necessary services, pointing out that medical decision-making must drive his code.

Time May Offer an Alternative 
 
Physician-patient time can help support the reported level of service. In the absence of extensive history and examination, pulmonologists may use time as the controlling factor when selecting an E/M service level if  the physician spends more than 50 percent of the visit on counseling and/or coordination of care (in the outpatient office, count face-to-face time with the patient; in the hospital, include time spent on the face-to-face service as well as unit/floor time that involves care focused on the patient). Otherwise, time is not a factor you should consider when selecting visit levels.

How it works: CPT indicates that 99214 or 99215 normally requires 25 and 40 minutes of the physician's total visit time, respectively. To report these services based on time, the physician must document the total visit time (which includes counseling time and other time spent obtaining history and exam and considering the decision-making), the amount of time spent counseling/coordinating care, and the points of discussion.