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Medical necessity for an E/M visit

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hanihosni

Contributor
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21
Location
New Port Richey, FL
If a patient has cancer and he's presenting with cancer-related pain that is controlled and there are no other problems, does that establish medical necessity for an E/M follow-up visit or would the visit be considered non-billable ?
 
hanihosni said:
If a patient has cancer and he's presenting with cancer-related pain that is controlled and there are no other problems, does that establish medical necessity for an E/M follow-up visit or would the visit be considered non-billable ?
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If a patient is in pain, that's in and of itself a sufficient reason for an E/M visit - I can't imagine why you might think this would be a non-billable service. Is it because this in the global period of a surgery? That would be a different question.

Generally speaking, it's not a coder's responsibility to judge the medical necessity of the services that a physician performs - we're simply not trained or qualified to do that. But if the organization you work for wants you to evaluate medical necessity, they should be giving you some guidelines for doing so, which would normally be with the input of a physician or other clinically trained provider.
 
As thomas asked, is this within the global period for surgery? I just want to be clear on why you're asking.

An EM visit for cancer-related pain would certainly meet most standards of medical necessity. Would it be billable? I need more information about why you're questioning it.
 
I'm questioning it because the pain is controlled by the medications he's already on and it's a follow-up visit for a palliative care patient seen in a hospital. He's being seen for the pain caused by the cancer and the cancer itself is at an advanced stage and nothing else can be done to treat it. Thank you for your input.
 
hanihosni said:
I'm questioning it because the pain is controlled by the medications he's already on and it's a follow-up visit for a palliative care patient seen in a hospital. He's being seen for the pain caused by the cancer and the cancer itself is at an advanced stage and nothing else can be done to treat it. Thank you for your input.
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If the patient is seeking the physician's help with this and the physician feels it worth their time to see and further evaluate the patient, then I would not question the medical necessity of it. There are many cases where nothing can be done to treat a particular problem, but that does not imply that the service isn't medically necessary or that the physician's time is not billable.
 
The problem I'm having with this note, is that it states that the pain is controlled and there are no other complaints at the time of the visit. The provider is listing the cancer in the assessment section but the it's not being addressed in the plan. I think that, from a coding perspective, medical necessity must be clearly demonstrated from the documentation. The question on my mind is this: if the pain is already well controlled, then why is the patient being seen in the first place ?
 
hanihosni said:
The problem I'm having with this note, is that it states that the pain is controlled and there are no other complaints at the time of the visit. The provider is listing the cancer in the assessment section but the it's not being addressed in the plan. I think that, from a coding perspective, medical necessity must be clearly demonstrated from the documentation. The question on my mind is this: if the pain is already well controlled, then why is the patient being seen in the first place ?
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Just because the pain is controlled doesn't mean there isn't medical necessity for the visit. Many conditions that are controlled (e.g. diabetes, hypertension just to mention two common ones), still need to be monitored periodically by a provider.

This is really a question for the provider, as are any medical necessity questions, in my opinion. Have you spoken to the provider about this? Ask them if a peer who reviewed the note would agree that the visit was medically necessary, and if they think not, then ask them to amend the note to make it more clear or get their approval to make it a no charge visit.

Coders aren't normally trained to be able to look at a record and know whether or not the standard of care for a particular patient symptom or condition makes an evaluation necessary. Does the practice that you work for require that you audit for medical necessity? If so, then they should be giving you guidance on how to go about this and what action is appropriate to take in the event that you identify that medical necessity is questionable (i.e. when to query, or to whom to refer the note for review, or when and whether they want you to make the visit a no-charge). There aren't coding guidelines for how to handle medical necessity - a coder's job is just to correctly and accurately report what is in the record, not to decide whether or not the physicians really needed to be doing the work that they did. If you feel the record might be vulnerable in an audit, then that's something that needs to be discussed with the provider. Just my thoughts on the matter.
 
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