# Medical Necessity - counting key components



## tg (Aug 14, 2013)

I would appreciate help with the following question.  When counting key components I often end up with a 99214, however the diagnosis is not very complicated, for example, canker sore, sore throat.  My question is do I downcode based on the medical necessity?  How do I downcode and when am I required to do this?  Again, thank you for your help; I am a new coder and have many questions that come up as I work...


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## mitchellde (Aug 14, 2013)

with that example of a diagnosis how are you getting to a 99214 based on the exam?  or even the decision making


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## tg (Aug 14, 2013)

When counting the History and Exam elements I end up with Detailed and Detailed and for an established patient I only need 2 out of 3, which leads me to a 99214.


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## mitchellde (Aug 14, 2013)

yes but how much of the history was "brought" forward from a previous exam?  it is for this reason most payers pay more attention to the exam and MDM.  I find it very hard to get a detailed exam for the kinds of dx you posted as examples, It might be beneficial if you were to post an example note for us to review and see if we all get the same answer.


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## PerriL2 (Aug 14, 2013)

It's not so much 'down coding for medical necessity' as it is counting the elements that pertain to the patient's illness.  Because medical necessity is the over arching criteria, you would only count the HPI, exam, and MDM elements that are necessary to treat 'canker sore, sore throat'.


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## tg (Aug 15, 2013)

Wow I never knew that.  One of the PAs I do coding for is very thorough and does an extensive ROS and Exam for most encounters - even just a sore throat, and that's how I end up with the 99214...


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## tg (Aug 15, 2013)

PerriL2, did you mean History in general as opposed to HPI?


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## mitchellde (Aug 15, 2013)

Here is a collection of bullet points from Medicare that I use in my presentations, It always seems to help clarify this very issue:
* Report an E/M service only when the service meets medical necessity requirements and document sufficiently to support the medical necessity of the E/M service reported. 
* Medical necessity is the overarching criterion for payment in addition to the individual requirements of a CPT code.
* Report and document the level of E/M service appropriate to treat the patient’s presenting problems. 
* The E/M code reported must reflect the patient’s needs, work performed and medical necessity. 
* an E/M service may be coded 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 (of their medical condition) does not require the code’s work.
And last of all I tell all those attending that while it is easy to perform and document a perfect level 4 or even 5 visit, the question is SHOULD you be performing that level given the patient's presenting issue(s)


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## tg (Aug 15, 2013)

Thank you for your response.  I am just wondering here what the point of counting the key components is if the overarching criteria which will determine the level of the E&M code is Medical Necessity.


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## MikeEnos (Aug 15, 2013)

Tovy I don't think you are understanding.  It's not as if you can just write down "Saw Mr. Jones, his cancer has metastasized."  and code that as a level 5 because of the medical necessity.  The documentation must support the level 5... so that's why you need to count the key components (History, Exam, Medical Decision Making Complexity.) 

What Deb is saying is that you can't just blindly count/score the key components and give a level of service.  If it were that simple, a computer could do it.  It would be quite easy for a provider who uses templated notes from an EMR to document a comprehensive history and comprehensive exam for every encounter.  That does NOT mean they are all 99215's..... even though by definition you only need to meet 2 out of 3 components for that code range.

You need to consider the medical necessity.  Was the extent of history and the extent of exam medically necessary and appropriate?  Medical necessity is the overarching criterion for payment, so it can hold back the level of the code, but you cannot use it as a reason to increase the level of the code beyond what the documentation supports.  

Now, be very careful with this concept.... we are NOT advizing you to start arbitrarily deciding what elements of the history or exam were not necessary.  We are not clinicians, and we do not know what the physician is considering as a differential diagnosis.  Just keep in mind that the code selection for a given level of service must be in line with the medical necessity.  The CPT manual describes the typical nature of the presenting problem for each level:

99201- Typically, the presenting problem(s) are limited or self minor.
99202- Typically, the presenting problem(s) are of low to moderate severity.
99203- Typically, the presenting problem(s) are of moderate severity.
99204- Typically, the presenting problem(s) are of moderate to high severity.
99205- Typically, the presenting problem(s) are of moderate to high severity.

99212 - Typically, the presenting problem(s) are self limited or minor.
99213 - Typically, the presenting problem(s) are of low to moderate severity.
99214 - Typically, the presenting problem(s) are of moderate to high severity.
99215 - Typically, the presenting problem(s) are of moderate to high severity.


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## tg (Aug 15, 2013)

Thank you very much for your clear response.  I am going to continue counting everything documented and see what level I come up with.  After that I will look at the nature of the presenting problem and determine if the code I have was medically necessary.  If it wasn't I will adjust the code accordingly.  Thank you everyone again.


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