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mhughes0301

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Hi all,

I am having some push back by providers on their audits. It is my understanding that a medically appropriate history and/or exam is a REQUIREMENT to bill for an E/M service. I have providers whom are trying to bill an E/M for MRI review. From what I have been taught and have been doing for years, MRI review is not enough to bill for an E/M.
As well as, you can not bill for an E/M without an exam or appropriate history. Obviously, this does not determine code selection anymore, but it is still a requirement to be documented. Am I incorrect in saying this?
I also have providers billing on time and because they are billing on time, they believe they do not need an exam or history at all, because their code is solely based on time.

Thank you in advance.
 
Read the beginning of the E/M services section in the CPT book. The header is History and/or Examination. If you have the hard copy 2025 CPT Professional Edition, it's on page 7. "E/M codes that have levels of services include a medically appropriate history and/or physical examination, when performed." Continue reading the paragraph and you will see it is not a requirement. The final sentence is, "The extent of the history and physical examination is not an element in selection of the level of these E/M service codes." However, while not technically a requirement to bill an E/M it would still be expected to see something to establish medical necessity, show continuity of care, and from a med-legal standpoint.
That being said, I think it depends on the setting, type of service, patient, and problem, etc. There could be some cases where you would not necessarily see these documented. What specialty are you reviewing? You definitely need a chief complaint/reason for visit.
As for the MRI review, it depends. Who ordered the MRI and performed the interpretation? If the provider is trying to take credit for an MRI they had already ordered and your practice billed for it in house, they can't get double credit by billing an E/M again later for reviewing it. If they are reviewing an outside/external MRI they did not order or get credit for prior, they can take credit for it later. Further, it depends on if they did an independent interpretation or just reviewed it. Second opinion scenarios have this.
For the time based, it again, depends on the documentation. There could be a case where they might not have an exam. It could be a complicated patient where they spent 60 minutes talking about options but no exam was needed.
This is all really dependent on the specific documentation of the encounter. However, if I was looking at a larger sample of a provider's notes over time, none of the notes ever had any history or exam - red flag. If every single visit was billed based on time with the exact same time statement, that would be cause for concern too.
CMS and others would be looking for: "Thus, when billing an E&M service, document the patient's condition, what medically necessary service(s) were provided, and the reasoning for those services, based on the patient's needs at that time."
If the provider is billing a 5 yet the reviewer can't tell what the patient was there for and see the thought process documented, it's not going to fly.
Old NAMAS commentary about this: https://namas.co/the-role-of-the-history-and-examination-in-2023-evaluation-and-management-services/
ACS: https://www.facs.org/for-medical-pr...visit-coding-changes/history-and-examination/
Coding Intel: https://codingintel.com/em-changes-history-and-exam/
“E/M Codes that have levels of services include a medically appropriate history and/or physical examination when performed. The nature and extent of the history and/or physical examination is determined by the treating physician or other qualified healthcare professional reporting the service. The care team may collect information and the patient or caregiver may supply information directly (e.g., by electronic health record portal or questionnaire) that is reviewed by the reporting physician or other qualified health care professional. The extent of history and physical examination is not an element in the selection of the E/M services.” CPT 2025 Professional Edition, AMA P. 7

There is a plethora of info about this when doing a search. Most of the MACs address this in the FAQ and E/M sections. The CMS EM services guide is currently under construction but would be found here: https://www.cms.gov/files/document/mln006764-evaluation-management-services.pdf
 
A medically appropriate history and/or exam is still required to bill an E/M visit. It must be performed and documented.
You can bill an E/M when the patient is present and the clinician provides an assessment and plan.
However if the note only says “MRI reviewed” with no evaluation/management and no medically appropriate history or exam, an E/M cannot be billed.

You may select the E/M level based on total time, but you must still perform and document a medically appropriate history and/or exam.

Here is a link to CMS and it says "Eliminated use of history and exam to determine code level (instead there would be a requirement for a medically appropriate history and exam)."


another link that might help AMA CPT E/M LINK might help https://www.ama-assn.org/practice-m...quired-document-time-spent-each-specific-task
 
Additional resources below. Do you have an example, redacted note to show? Again, if talking specifically about "MRI" review. It depends on the documentation and: Who ordered the MRI and performed the interpretation? If the provider is trying to take credit for an MRI they had already ordered and your practice billed for it in house, they can't get double credit by billing an E/M again later for reviewing it. If they are reviewing an outside/external MRI they did not order or get credit for prior, they can take credit for it later. Further, it depends on if they did an independent interpretation or just reviewed it.

Playing devil's advocate, if there is a chief complaint documented, you have an EHR and ancillary staff documents some form of history, the provider says how the patient appears and vitals were taken, wouldn't that count as a minimal history and/or exam? Not saying it's great or right, just sayin! Sometimes I suggest coders use the "old" 95/97 audit sheets just to see what comes out and use that thinking process just to see how it comes out the "old" way. But again, it all depends on the specific documentation of each encounter. There's no catch all or black/white answer.

This is from Novitas JL, E/M FAQ section (I used this MAC since the OP location shows Maryland).

FAQs: Evaluation And Management Services (Part B)

www.novitas-solutions.com www.novitas-solutions.com
"5. Is the documentation of history and examination required when scoring office/outpatient services under the revised 2021 guidelines?
The approved revisions do not materially change the three current MDM elements, but instead provide extensive edits to the elements for code selection and revised or created numerous clarifying definitions in the E/M guidelines.
While the provider’s work in capturing the patient’s pertinent history and performing a relevant physical exam contributes to both the time and medical decision making, these elements alone should not determine the appropriate code level.
The revised code descriptors state a "medically appropriate history and/or examination" is required."

This is from the AMA: https://www.ama-assn.org/system/files/2023-e-m-descriptors-guidelines.pdf
"History and/or Examination ►E/M codes that have levels of services include a medically appropriate history and/or physical examination, when performed. The nature and extent of the history and/or physical examination are determined by the treating physician or other qualified health care professional reporting the service. The care team may collect information, and the patient or caregiver may supply information directly (eg, by electronic health record [EHR] portal or questionnaire) that is reviewed by the reporting physician or other qualified health care professional. The extent of history and physical examination is not an element in selection of the level of these E/M service codes.◄"

CMS: https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/downloads/clm104c12.pdf
"B. Selection of Level of Evaluation and Management Service
As of January 1, 2023, for most E/M visit families, practitioners will select visit level based on the level of medical decision making (MDM) or the amount of time spent by the physician or non-physician practitioner. For some types of visits (such as emergency department visits and critical care), in accordance with their CPT codes, practitioners do not have this choice and will use only MDM or only time to bill. The CPT E/M Guidelines for MDM apply. For all E/M visits, history and physical exam must be performed in accordance with code descriptors, but history and exam no longer impact visit level selection. When practitioner time is used to select visit level, the full time must be completed; the general CPT rule regarding the midpoint for certain timed services does not apply."
 
I just would like to say Thank to both of you for your comprehensive responses with links to the valuable resources! So much to learn! :) Thank you for sharing. We, all, are learning from your experiences.
 
Thank you all for your responses. I did get backup from an outside coding group that confirmed you do need a medically appropriate history and/or exam to bill for an e/m. I appreciate all of your responses
 
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