Medical Necessity beyond purview.

baroquecoder

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I am being told that validating E/M's to some extent is beyond my purview.
Specifically medical necessity. I am being told that it is beyond my scope to recognize/question/or
validate E/Ms with regard to their medical necessity. I am being told that we are to 'assume' that
if the MD states in the impression a particular condition, that the condition was addressed, whether
or not present in ROS/EXAM components or HPI. This goes against my understanding of ICD-10 coding
for outpatient claims. I only code what was treated and/or relevant to that episode of care, everything else,
if not managed, evaluated, assessed and/or treated is not reported or relevant. Wouldn't this ultimately
affect the level of MDM or the level of E/M? I'm feeling a bit conflicted this morning about what elements of
the E/M I'm allowed within my scope to validate/question/confirm/clarify and code based on my credentials
and job description. I am a CCS, CPC and CCC. I intend to also be a CEMC very soon!
 

thomas7331

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As a general rule, I do agree that medical necessity is something that is outside the scope of coding. But your question involves some other things are not really medical necessity, so I'll try to give you my perspective on each.

Medical necessity, in the context of E&M coding, basically enters into the picture when the level billed exceeds what is normally required to treat a particular condition. In my experience, this usually comes about because providers have 'over-documented' to try to meet the numbers of elements needed for a higher level code. The problem that a coder is faced with is how to determine which of those elements were not necessary - in other words, what organ systems or body areas didn't need to be reviewed or examined in order to treat the patient, which tests didn't needed to be ordered or reviewed, etc. That is truly a clinical decision, and while it's important to be conscious of up-coding and to talk to your providers about this, I've always believed that coders should not undertake this kind of thing without a provider's input and guidance. Providers spend many years learning how to diagnose and treat a patient and it's not the place of a coder without that training to step in and say that something was or was not necessary, nor is it a provider's job to justify in the medical records the necessity of everything they do - that should be part of a peer review process, not a coding and documentation exercise.

Now the other things you mention actually do fall into a coder's scope. Coders are trained to evaluate provider documentation and follow the guidelines about what should be reported based on what is in the documentation. So you're correct, that if there is no documentation that a problem is addressed in the encounter or has a role in the treatment, then per the guidelines, you would not report the ICD-10. Although the reporting of ICD-10 codes by itself does not affect E&M levels, there would be no argument for counting those problems toward the MDM for E&M level if there is no documentation that the problems played any role in the provider's MDM, so it is incidentally related. The 1995 E&M guidelines lay out the documentation principles to guide coders in all this, and it is certainly within scope to apply this in your work and use that information to educate providers about supporting their coding with good quality notes. This is about quality documentation and correct coding, not medical necessity.

All that said, it's also within your organization's rights to create some internal guidelines on how and where they want their coders to focus their skills and efforts, so if they've established a process for you as to what your role will be, and as long as you're not asked to do anything unethical, then that's all part of the job, and I'd just encourage you to talk over your concerns in an honest manner with the people you work with and work for so they understand where you're coming from and you can better understand where they are.

Hope this helps some!
 
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baroquecoder

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Re-adjusted!

As a general rule, I do agree that medical necessity is something that is outside the scope of coding. But your question involves some other things are not really medical necessity, so I'll try to give you my perspective on each.

Medical necessity, in the context of E&M coding, basically enters into the picture when the level billed exceeds what is normally required to treat a particular condition. In my experience, this usually comes about because providers have 'over-documented' to try to meet the numbers of elements needed for a higher level code. The problem that a coder is faced with is how to determine which of those elements were not necessary - in other words, what organ systems or body areas didn't need to be reviewed or examined in order to treat the patient, which tests didn't needed to be ordered or reviewed, etc. That is truly a clinical decision, and while it's important to be conscious of up-coding, I've always believed that coders should not undertake this kind of thing without a provider's input and guidance. Providers spend many years learning how to diagnose and treat a patient and it's not the place of a coder without that training to step in and say that something was or was not necessary, nor is it a provider's job to justify in the medical records the necessity of everything they do - that should be part of a peer review process, not a coding and documentation exercise.

Now the other things you mention actually do fall into a coder's scope. Coders are trained to evaluate provider documentation and follow the guidelines about what should be reported based on what is in the documentation. So you're correct, that if there is no documentation that a problem is addressed in the encounter or has a role in the treatment, then per the guidelines, you would not report the ICD-10. Although the reporting of ICD-10 codes by itself does not affect E&M levels, there would be no argument for counting those problems toward the MDM for E&M level if there is no documentation that the problems played any role in the provider's MDM, so it is incidentally related. The 1995 E&M guidelines lay out the documentation principles to guide coders in all this, and it is certainly within scope to apply this in your work and use that information to educate providers about supporting their coding with good quality notes. All that said, it's also within your organization's rights to create some internal guidelines on how and where they want their coders to focus their skills and efforts, so if they've established a process for you as to what your role will be, and as long as you're not asked to do anything unethical, then that's all part of the job.

Hope this helps some!
Thank you! Your words of fact and perspective are exactly what I needed. I believe I was going beyond the call of duty, when my role is to just validate that services were provided. We are required to validate level 5 key components routinely, so I will focus on those without too much interpretation of what is medically necessary, but what meets documentation requirements for a level 5. You are absolutely right about what you say! I feel I am sufficiently turned back around and re-focused on my role. Thank you for your thoughtful and insightful prose.
 
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