E/M level and medical necessity


Beach, ND
Best answers
I have a note that is comprehensive History, comprehensive exam, and MDM falls into moderate. So, that leads to a 99215 for this office visit. But the provider actually selected 99213. I'm new to coding, just finished my course and trying to be very thorough and as follow the check list to pick the right e/m each time. I'm wondering if he selected a lower e/m due to medical necessity, but he is doing a referral to cardiology, patient has sore/painful mouth with a history of BCC in that location so trying OTC and if no better, possible referral.. does the referral to cardiology make the risk moderate? Other than that, no mention of rx meds, but I'm thinking between the referral and a chronic illness with exacerbation (mouth sore/hx of BCC) that qualifies for moderate.

his history has 4 HPI elements, CC, all the histories, complete ROS. Exam covers 14 areas, in detail but not all overly in depth. Those together qualify for the 2/3 needed for a 215, right?

Or should it be a 214? I think it definitely can qualify for more than 213. I just second-guess myself and don't want to do it incorrectly and get in a bad habit.
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Based on strictly a number game you would correct that using an established patient criteria that your information levels to a 99215:
* History = 4 HPI elements, CC, all the histories, complete ROS.
* Exam = 14 areas

In regards to medical necessity, you would need to take into account the full patient record for the date of service, it is difficult in this environment without chart access to provide much direction. A referral to another provider does not automatically reduce the level of medical necessity or the actual CPT code.

In a case like this I would present my review to the provider and through a verbal discussion see if there was a reason that he coded lower than initially determined during your review. Sometimes it is as simple as they do not realize that their documentation warranted a higher level. This is a great opportunity for learning for both you and the provider. Good luck!
COMP HX & COMP EXAM do not automatically add up to a 99215. Remember, CMS states that "Medical Necessity" is the over-arching factor in determining the level of an E/M. As a basic rule, your code level should never be higher than the MDM. In this case the only way that you could justify billing a 99215 is if every single history component and every single exam component was "Medically Necessary" and you as a coder probably do not have enough pathophysiology and anatomy to make that decision. My guess would be if you looked at your diagnosis' being managed, not every single HPI, ROS, PFSH and exam element would be considered "Medically Necessary". But I could be wrong, and only your physician could make that determination. The advice that I would give you would be to never bill an E/M that is higher than the MDM.