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Wiki Overarching criteria vs documentation guidelines

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dmayes

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Hello
I'm curious how many of you use Overarching criteria (medical necessity) to drive your E&M level choices vs leveling a E&M based soley off of documentation?
 
If you are not taking medical necessity into consideration, you are going to find yourself in a lot of trouble with payers. Ignoring medical necessity its easy to get a level 5 on every established patent visit. Say your Dr did a comprehensive history and exam for a splinter or the common cold are you really going to bill a level 5? Expect an auditor to be knocking on your door.
 
Coding King is exactly right. You must have medical necessity to justify billing for a medical visit but the provider shouldn't be doing "extra" unnecessary steps just to inflate the code level.

Huge red flag when the carriers compare E/M codes used among different providers and see one that consistently bills a high level code for a low complexity MDM diagnosis.

Tom Cheezum, O.D., CPC
 
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