Wiki Medical Necessity for E&M

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AmyCPCCPCH

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Hello everyone. I am having a problem with a provider who can dictate enough information for a level 5 but really for the problem it should be a level 3. The problem is, is that it is an established patient so the physician only needs 2 out of 3 components. He dicatates a great history and does a great exam so he gets his 2. His history and exam actually never changes. It is the same word for word for the last 2 months. Is there anything that says there has to be some type of medical necessity for that level or that many exams, he is seeing the patient every other week, even if he does have a comprehensive history and comprehensive exam documented. I have looked on Medicare's website and have not seen anything. I need more of a reason to deny these claims besides I know you have been copying the same note for the last two months your plan just says follow up as planned. I know the medical decision making is not being met. Thanks for your help.
 
Per Medicare's Claims Processing Manual on p. 33 here:

Ch. 12
Section 30.6.1 A.

"Medical necessity of a service is the overarching criterion for payment in addition to the individual requirements of a CPT code. It would not be medically necessary or appropriate to bill a higher level of evaluation and management service when a lower level of service is warranted. The volume of documentation should not be the primary influence upon which a specific level of service is billed."

Seth Canterbury, CPC, ACS-EM
 
Also read this info about cloning from AHIMA's infocenter here:

Fraud and Abuse
Billing Concerns
Although there has been no official directive or comment from the Centers for Medicare and Medicaid Services (CMS), much has been written about copy notes from the local (state) Medicare carriers. Cigna Government Services Medicare of Idaho has written, “Cloning of documentation will be considered misrepresentation of the medical necessity requirement for coverage of services. Identification of this type of documentation will lead to denial of services for lack of medical necessity and recoupment of all overpayments made.”1

Guidelines on cloning from First Coast Service Options include:
“Documentation is considered cloned when each entry in the medical record for a beneficiary is worded exactly like or similar to the previous entries.” “Cloning also occurs when medical documentation is exactly the same from beneficiary to beneficiary.” “It would not be expected to see that every patient had the exact same problem, symptoms, and required the same treatment.” The cloning policy “is not specific to EHRs, but applies to medical documentation in any format.”2

1. Cigna Government Services.“Medical Record Cloning Documentation Reminder.” Medicare Bulletin, Part B. March/April 1999. 2. First Coast Service Options. “Requirements for the Payment of Medicare Claims—A Selection of Some Important Criteria.” Medicare B Update! 4, no. 3 (third quarter 2006). Available at www.floridamedicare.com/Part_B/Medicare_ B_Update/Archive/106399.pdf.
 
My two cents...

I agree with SCanterbury. Medical decision making should be one of the key factors in code selection. For established patients, two elements are needed BUT medical necessity should be one of the two components considered.
From your example, it sounds like your physician is documenting a comprehensive history and exam, but the medical decision making is not as high (maybe it's at a low complexity). In this case, I would code the visit as a 99213 according to the medical decision making. If the code is picked based on the history and exam, the overarching criteria would say that the physican is over-billing (even though two components are met). In this example, charging a 99215 is not necessary when the medical decision making is only at a low level.
Also, notes that appear to be copied from visit to visit is a compliance red flag. I would discuss this with your physician and encourage him/her not to copy history from past visits. A more acceptable practice may be for him/her to reference certain history elements citing the previous visit date.
That's my two cents. I hope this was of help to you :)
 
Please be aware that medical decision making is NOT the same as medical necessity. When coding an established patient or follow-up visit, it does NOT have to be one of the two component scores used. It CAN be the lowest level that is discarded.

For example, the nature of the presenting problem may warrant a level 5 hx and exam on an established patient. However, the problem is not as severe as was feared possible at the beginning of the encounter, so the medical decision making is only scored at 4. There is no indication that the provider went overboard in the history/exam to get more reimbursement. This amount of hx/exam was necessary in order to get to the root of the problem, since the symptoms the patient presented with could have been caused by any of a number of problems. There was clear medical necessity for the extensive hx/exam that was needed to help figure out which diagnosis was correct for this patient. In this case, there is absolutely nothing wrong with billing based on the hx and exam scores, even though they are higher than the MDM score. There is no rule that says it has to be one of the two component scores used for f/u or established encounters, and some Medicare carriers, like Florida's First Coast Service Options, have even put in writing that MDM does not have to be used.

Seth Canterbury, CPC, ACS-EM
 
Yes--you are correct that there is no official rule saying that MDM has to be one of the components cosidered in code selection. Sorry for any confusion!
I guess this has become one of the trends I try to follow when I'm auditing. My physicians sometimes over document and this has helped me see when overdocumentation is occuring.
After reading your example, it makes sense that a high level history and exam would be necessary even if the MDM is not as high. We don't run into scenarios like this very often (if at all) so I've never considered the possibility. Thanks for the clarification :)
 
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