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Thread: coding according to nature of presenting problem

  1. #1

    Default coding according to nature of presenting problem

    AAPC: Back to School
    Can anyone direct me to the source that discusses the fact that the e/m code should reflect the nature of the problem and not solely on amount documented? I have looked in the cpt bbook and in the cms eval/man guidelines and cannot find it in either place.

  2. #2
    Join Date
    Apr 2007
    Lubbock, TX


    Quote Originally Posted by melissatwy View Post
    Can anyone direct me to the source that discusses the fact that the e/m code should reflect the nature of the problem and not solely on amount documented? I have looked in the cpt bbook and in the cms eval/man guidelines and cannot find it in either place.
    There's a couple of places...first as a CMS guideline:
    "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."

    https://www.cms.gov/transmittals/downloads/r178cp.pdf (Page 2)

    Also, Trailblazer Medicare (our local carrier) has this article:

    If you live in another part of the country, I'd be willing to bet my next paycheck that your LCD's will have a similar stance, but you should always check. I searched "Trailblazer medicare E/M level medical necessity" on Yahoo and that page was the first one to pop up. Hope that's what you needed!

  3. #3
    Join Date
    Apr 2007
    Lubbock, TX

    Lightbulb Found another one...

    This is the one I meant to give you from Trailblazer...that other one kind of sucked (sorry)...


    Medically Reasonable and Necessary
    The law requires all payments (with only a few exceptions) made by Medicare to be for medically reasonable and necessary services. Medicare determines “medically reasonable and necessary” separately from determining that the work described by a reported CPT code was performed. For E/M services, the medical record documentation must demonstrate that the practitioner performed the reported E/M service as it is described in the CPT book and as required by CMS E/M Documentation Guidelines. Additionally, it must support the intensity and frequency of the E/M service met but that it did not exceed the patient’s clinical needs. Information within the medical record about the patient’s condition, not the diagnosis alone, determines the level of service payable by Medicare. In keeping with federal law, Medicare must deny or downcode E/M services that, in its judgment, exceed the patient’s documented needs.

    Documenting Medical Necessity
    The patient’s condition (severity, acuity, number of medical problems, etc.) is the key factor in determining medical necessity for Medicare payment for services. Providers who report E/M services for Medicare payment must ensure their records describe the patient’s condition and reason for the visit in enough detail for a reasonable observer to understand the patient’s need. Providers must also ensure the nature of the patient’s presenting problem and/or status is consistent with the level of service reported. Unfortunately, practitioners often include unnecessary material while failing to record clinically pertinent information needed to determine medical necessity of the service. The service should be coded based on the clinical needs of the patient.

    Level of Service
    The E/M code chosen must reflect both work performed and medical necessity. Though an E/M service may code to a high level based on the documentation of key component work, it is inappropriate to request Medicare payment when the patient’s effective management does not require the code’s work.

    Comments on the Sample
    The patient presented with a single, chronic, well-controlled problem. Unfortunately, the practitioner’s explanation of the nature of this patient’s problem is too vague to even get a sense of whether this service is at all medically necessary. Osteoarthritis is a chronic problem that appears to be stable in this patient. Is a three-month follow-up reasonable and necessary for stable osteoarthritis? Why or why not? Those are the questions the information in the record should address for Medicare payment to be determined appropriate.
    If one assumes this was a medically reasonable and necessary visit, what level of service is needed for a follow-up visit with a patient who has one stable problem (for which the likelihood of death or disability before the next visit is very unlikely)? The answer is that this visit would appropriately be paid as a low-level E/M service, probably code 99212. Consequently, while the very brief HPI and Medical Decision-Making (MDM) could be appropriate for the care of this patient’s osteoarthritis, the comprehensive ROS and examination exceeded the level of care needed for the patient’s presenting condition."
    Last edited by btadlock1; 03-06-2011 at 05:48 PM. Reason: looked funny

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