# Medical Necessity for Physical Examination



## PAMALAR (Mar 30, 2011)

In the hospital I am working, I noticed over documentation of Physical examination which is leading to higher level of E&M. Example: for established office visit (2 out of 3 key component required) with history and physical examination as comprehensive with a severity of illness very low, the system automatically gives a higher level of E&M.


Can anyone help me in finding good articles and guidelines on physical examination documentation so that we can educate our physicians regarding medical necessity for the same. I remember i read one in Coding edge/Edgeblast, but cannot remember which edition it was.

Please help...
THANKS
Pamalar CCS, CPC


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## btadlock1 (Mar 30, 2011)

PAMALAR said:


> In the hospital I am working, I noticed over documentation of Physical examination which is leading to higher level of E&M. Example: for established office visit (2 out of 3 key component required) with history and physical examination as comprehensive with a severity of illness very low, the system automatically gives a higher level of E&M.
> 
> 
> Can anyone help me in finding good articles and guidelines on physical examination documentation so that we can educate our physicians regarding medical necessity for the same. I remember i read one in Coding edge/Edgeblast, but cannot remember which edition it was.
> ...



Maybe this will help... 

http://www.justcoding.com/263947/medical-necessity-is-an-em-service-imperative
"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."


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