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Thread: Medically Necessary

  1. #11
    Join Date
    Apr 2007
    Milwaukee WI

    Default Medical Necessity

    AAPC: Back to School
    CMS Guidelines states: "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 to bill a higher level of E/M 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."
    Emphasis added by FTB ...
    (I'm sorry I don't have a link for you ... I got this quote from from a seminar.)

    I attended a presentation by a physician who does the education for new practioners in her practice (100+ physicians); she came up with a "simplified table of risk" where she only looked at the presenting problem. Why?
    "Because that's how physician's think," was her explanation. She commented that she wanted to get away from automatically going to "moderate risk" just because a prescription was written (her example was for sinusitis, by the way). She wanted to train the physicians to take into account the medical necessity, based on the presenting problem, of performing a detailed history or a comprehensive exam. So she asked them to FIRST decide on the level of risk based on presenting problem, and THEN document the history and exam, order labs, etc, to fit that level of risk.

    Now, I'm not saying - nor was she - that in auditing you wouldn't take Rx into consideration, but when the physicians took this approach to their documentation they typically chose a level 3 visit for problems such as sinusitis ("acute uncomplicated illness or injury" - i.e. low risk).

    If I audited this note I'd give credit for the level 4 that is documented. HOWEVER, I think it should be a level 3 based on the presenting problem.

    F Tessa Bartels, CPC, CPC-E/M

  2. #12
    Join Date
    Apr 2007
    Duluth, Minnesota


    Tessa, I've heard of that MDM "first" type of coding -... my personal opinion on it is - I don't like it.... The auditors I've had the opportunity to work with didn't like it either - I've read articles both for and against the habit of "reverse level determination". I tend to lean towards that "nay" side of it.

    I would agree however that documentation "alone" does not a level make - you could have 3 pages of dictation and it might still only be a level 2 or 3 or two paragraphs that will reflect a level 4 or 5!! It's what's "IN" the documentation, it's what exactly the doctor states and does that determines the level. I've had sinusitis visits that were level 2 or 3, and some that are 4, it just depends on documentation and services provided.

    hey all - have a MERRY CHRISTMAS!
    Donna, CPC, CPC-H

  3. #13


    Thank you so much to everybody for your input! I think it qualifies as a 99214 as well but wanted to see if anybody agrees. Sometimes coding can drive me nuts! Never boring!


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