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E/M's: Time vs. Medical Necessity

  1. #1
    Default E/M's: Time vs. Medical Necessity
    Medical Coding Books
    I need opinions please.

    I understand that time can become the controlling factor if counseling/coordination of care are documented, but does medical necessity get to play a role at all?

    How can a high-level (99215) be justified when it's for a problem focused exam with low level MDM, but they spend over 40 minutes with the patient including 20 mins talking about wellness/self-care? This is not a sick patient.

  2. #2
    Default
    Quote Originally Posted by krislein View Post
    I need opinions please.

    I understand that time can become the controlling factor if counseling/coordination of care are documented, but does medical necessity get to play a role at all?

    How can a high-level (99215) be justified when it's for a problem focused exam with low level MDM, but they spend over 40 minutes with the patient including 20 mins talking about wellness/self-care? This is not a sick patient.
    If the patient's not sick, you don't bill a problem-oriented code - no matter how long the physician spent discussing things with the patient. (If there's a chief complaint, then it's a sick visit; otherwise, it's a preventive E/M). There are specific codes to report time spent in preventive counseling, which should be utilized, if that was the content of the discussion.

    In my opinion, medical necessity should limit the level to what was required to assess and manage the presenting problem(s), regardless of time. (The AAPC's practice exams for the CPC test, do not agree with me, apparently...there's actually a question very similar to this scenario) If the visit length was 40 minutes, and more than 1/2 of that was documented as counseling/CoC, time can be the controlling factor in selecting the level, versus the History, Exam, & MDM scores.
    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."

    I interpret that to mean: You can only bill up to the level that was medically necessary, but you can get there by meeting the code definition's requirements, by either having enough of the key components, or by the amount of time, when applicable. So, if a 99213 is all that's medically necessary, then that's the highest code you can get to, no matter how much documentation you have. But, that's only my opinion...

  3. #3
    Location
    Ellenville, New York
    Posts
    1,176
    Default Since we are sharing opinions...
    What troubles me about the CMS statement that Brandi posted is who really determines what is "Medically necessary"??? Using Krislein's example, if that counseling about wellness is given to a patient with a serious condition such as cancer, CVA, etc, then that patient would need that kind of counseling. But what about the patient who just discovered that she had DM? Not life-threatening, but certainly life-changing if the disease is to be controlled, and I am sorry, the proper counseling that may be required cannot be just done in 10-15 minutes just because some bureaucrat decides that DM doesn't warrant a longer counseling session.

    I understand and agree with the spirit of the statement - we don't want level 4 and 5's on things like sore throats and runny noses simply because of the volume of documentation in the history and exam, but there has to be some kind of guide that will help what this overaching criteria will be for determining what is medically necessary.

    Lance Smith, MPA, COC, CPMA, CEMC, RHIT, CCS-P, CHC, CHPC

    Director, Health Information Management
    HealthAlliance of the Hudson Valley
    Kingston, NY


    2016 Secretary
    Ellenville, NY Local Chapter

  4. #4
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    Quote Originally Posted by MnTwins29 View Post
    What troubles me about the CMS statement that Brandi posted is who really determines what is "Medically necessary"??? Using Krislein's example, if that counseling about wellness is given to a patient with a serious condition such as cancer, CVA, etc, then that patient would need that kind of counseling. But what about the patient who just discovered that she had DM? Not life-threatening, but certainly life-changing if the disease is to be controlled, and I am sorry, the proper counseling that may be required cannot be just done in 10-15 minutes just because some bureaucrat decides that DM doesn't warrant a longer counseling session.

    I understand and agree with the spirit of the statement - we don't want level 4 and 5's on things like sore throats and runny noses simply because of the volume of documentation in the history and exam, but there has to be some kind of guide that will help what this overaching criteria will be for determining what is medically necessary.
    It does seem pretty arbitrary; the only reference I've ever been given to determine the approximate medical necessity, in the 'clinical examples' in appendix C. In the end, it's up to the doctor to decide if they think that the content of the visit warrants a high level E/M - I would just caution them to have stellar documentation to back their decision up, if the E/M's being bumped up to a higher-than-usual level, based on time, alone.

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