Wiki 2021 E/M- Medical Necessity

[NicoleSprecher]

I have a question regarding the new 2021 E/M guidelines. I am coding and also performing audits by using the Namas audit tool. After all the webinars and workshops I did to prepare for the 2021 change I was never made aware of that there are steps within the audit to validate the medical necessity and not to only use the MDM to select level of service.
Wondering if anyone could advise on this? Do you also use a medical necessity formula that could trump the MDM?
Any advice would be great! Thank you so much!

 

[Cheezum51]

Just my opinion. I don't know that there's a medical necessity formula to trump MDM. Even with the new E/M guidelines, you still have to show medical necessity in the exam record in order to bill the exam to any medical insurance. When I "audit" for medical necessity, I look at the History area of the record. In spite of there being no minimal history criteria under the new guidelines, the provider still needs to show medical necessity in the CC and HPI or even in the ROS and medication list. Then something needs to be documented in the exam portion of the exam showing that the problems documents in the Hx portion were addressed in some way and finally, the Assessment/plan needs to show some conclusion as to whether the problems need further care or treatment. Finally, I look at the ICD-10 codes billed to see if they match the above.

If any provider believes the new E/M guidelines are going to allow them to say something like: CC: frontal HAs 3 days per week on average x 1 month, Tylenol no help. And then jump to the A/P and simply state something like: Sinus HAs. pt to use OTC Zyrtec PRN.

And have that pass as a level 4 exam because you have a new problem and medication management, they're going to get a rude awakening IMHO.

Tom Cheezum, OD, CPC, COPC