Urgent Care E/M Coding Question

rkramer

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In an urgent care facility setting some of the providers are submitting Level 4 codes (99204, 99214) documenting Complete Histories, Complete ROS and Complete Exams for both new and established patients who come in to be seen for complaints diagnosed as allergic rhinitis, sinusitis, sore throat, uti-no complications, contusion of finger. Although the documentation will support the Level 4 with moderate MDM using the 1995 E/M Guidelines, I'm questioning the medical necessity of the documentation for what seems to be more problem focused HPI. Can someone please clarify the importance of medical necessity in medical records documentation? Is there such a thing as "too much" documentation, especially with EMR?
 

btadlock1

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In an urgent care facility setting some of the providers are submitting Level 4 codes (99204, 99214) documenting Complete Histories, Complete ROS and Complete Exams for both new and established patients who come in to be seen for complaints diagnosed as allergic rhinitis, sinusitis, sore throat, uti-no complications, contusion of finger. Although the documentation will support the Level 4 with moderate MDM using the 1995 E/M Guidelines, I'm questioning the medical necessity of the documentation for what seems to be more problem focused HPI. Can someone please clarify the importance of medical necessity in medical records documentation? Is there such a thing as "too much" documentation, especially with EMR?
It's a contentious question, but here's what CMS says:
"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. Documentation should support the level of service reported. The service should be documented during, or as soon as practicable after it is provided in order to maintain an accurate medical record."

See: http://www.aafp.org/fpm/2006/0700/p28.html
 
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rkramer

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Thank you for your quick reply. Your information, along with the link you provided, is very helpful. My coworker and I are in the compliance dept. and trying to gather information that will be helpful in educating the physicians.
 
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