# Medically Necessary



## meganpoelzer (Dec 23, 2008)

Does anybody have any tips on how to determine medical necessity for a presenting problem? 

Example, patient presents with sinus pain/pressure and cough.
Based on what's documented:
HPI=Detailed
Exam=Expanded
MDM=Moderate (new problem, prescription drug management, dx=sinusitis)

According to what's documented, this is a 99214 but I am unsure if this OK based on the medical necessity of the problem.

I don't see any good equivalent clinical examples for this in CPT.


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## apeck (Dec 23, 2008)

I don't believe a 99214 is appropiate in this case. How many ROS was done on this exam? How much time did the Dr. spend face to face with the patient? Did they do any type of labs? From what I have learned this may only qualify as a 12 or a 13. A 14 is rare to give to a visit such as this, a 14 is running a marathon and spending at least 45 minutes with the patient. For example a 15 is usually only given if the Drl. is performing CPR on a patient getting into an ambulance on the way to the hospital. Example,I do child health and if the Dr. did a pulse ox meter, nebulizer treatment, a peek flow meter, another pulse ox, another neb treatment, peak flow and gave scripts and has to be well documented with the time in between neb treatments and complete ROS then they would get a 14. If you would like more info on choosing an e/m code you might want to check out www.emuniversity.com for more help. Good luck


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## dmaec (Dec 23, 2008)

I have to respectfully disagree with apeck.  Although, I couldn't say for certain that the criteria for a 99214 are met by what you've posted, it IS possible that this service does suppport a level 4 E/M.  
apeck states "a 14 is running a marathon and spending at least 45 minutes with the patient."  this is not true - a 99214 "typically" is about 25 minutes face to face with patient. (besides, you aren't coding/billing by "time") are you?
you simply need to meet two of the three component's to get a level 4, and from the information you gave - it is a level 4
HPI=Detailed
Exam=Expanded
MDM=Moderate
When you question the medical necessity of this visit, wouldn't the medical necessity be the fact that this issue has brought them to the doctor with a medical issue (a CC) that needs to be addressed.  If the doctor does a DETAILED HISTORY/ EXPANEDED EXAM and MOD MDM and documentation supports it -


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## JenniferVC (Dec 23, 2008)

I agree with dmaec. If you are billing by time then you would consider time, which a 14 is 25 minutes not 45 minutes. Also, you do have 2 components out of 3 for this service which is what is required to bill it. So I say you are ok to bill a 14.


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## apeck (Dec 23, 2008)

Please check the link I gave you for the e/m university and click on  the office visits and then click on the 99214 link and check out an example. This is usually done for patients with chronic diseases and the management of the disease. Also is this a new or established patient and it should help you to choose a level of service more fitting to the issue. I still think a 14 is to high of a level of service for sinusitis. I stand corrected on the time factor but the documentation still has to support the level of service. Just so you know I do not code by time, but it is  still a factor.


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## mkj2486 (Dec 23, 2008)

Well, after looking at emuniversity.com I still agree with dmaec. From what is posted there is enough for a level 4.  This is straight from the website: 

E/M University Coding Tip : As noted above, the 99214 is the second most common CPT code used by all physicians combined.  It is second only to the 99213.  The 99214 was charged a total of 49,912,657 times in 2003.  However, despite these impressive numbers we believe that the 99214 remains the most inappropriately UNDER-utilized code in the book.  This level of care requires only Moderate Complexity Medical Decision-Making.  If you objectively review the requirements for this level of cognitive labor, you will probably agree it seems congruent with the clinical circumstances of most “routine” encounters.  But for some reason, physicians tend to use the 99213 code to charge for encounters they perceive as being “routine” even though the 99214 would be a better fit.  The take-home message is simple: “Routine” does not always equal “Low Complexity” when it comes to Medical Decision-Making.  If you take the time to systematically quantify the Medical Decision-Making by utilizing the MDM Points System, you can avoid this form of chronic undercoding.


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## dmaec (Dec 23, 2008)

mkj2486 - WOW!  GREAT post!  awesome bit of info! thanks so much for sharing it!


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## apeck (Dec 23, 2008)

If you like her post you can get more info from the web link I posted for it @ www.emuniversity.com. I had a feeling someone was going to copy and paste that tip on this thread but I still do not agree with a 99214, that's my story and I'm sticking to it!!!


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## pamtienter (Dec 23, 2008)

I would start to question the medical necessity of the visit if the history and exam were high but the MDM was low. In this instance the MDM was moderate, so backed up by the exam, I'd go with a 99214. It may not be the norm for sinusitis, but it meets the criteria given here.


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## Lisa Bledsoe (Dec 23, 2008)

I agree with those who are stating code 99214.  If you meet two of three key components and one of them is MDM, that's the code you should report.  In this case,  I think of it in terms of *risk* in prescribing an antibiotic.  The doctor doesn't know what kind of reaction the patient may or may not have to the medication...he/she is taking a risk in giving an Rx. The documentation _as described _does support 99214.


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## FTessaBartels (Dec 24, 2008)

*Medical Necessity*

CMS Guidelines states: "*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 to bill a higher level of E/M 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."* 
Emphasis added by FTB ... 
(I'm sorry I don't have a link for you ... I got this quote from from a seminar.)

I attended a presentation by a physician who does the education for new practioners in her practice (100+ physicians); she came up with a "simplified table of risk" where she only looked at the presenting problem. Why? 
"Because that's how physician's think," was her explanation. She commented that she wanted to get away from automatically going to "moderate risk" just because a prescription was written (her example was for sinusitis, by the way).  She wanted to train the physicians to take into account the medical necessity, based on the presenting problem, of performing a detailed history or a comprehensive exam. So she asked them to FIRST decide on the level of risk based on presenting problem, and THEN document the history and exam, order labs, etc, to fit that level of risk. 

Now, I'm not saying - nor was she - that in auditing you wouldn't take Rx into consideration, but when the physicians took this approach to their documentation they typically chose a level 3 visit for problems such as sinusitis ("acute uncomplicated illness or injury" - i.e. low risk).

If I audited this note I'd give credit for the level 4 that is documented. HOWEVER, I think it should be a level 3 based on the presenting problem. 

F Tessa Bartels, CPC, CPC-E/M


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## dmaec (Dec 24, 2008)

Tessa, I've heard of that MDM "first" type of coding -... my personal opinion on it is - I don't like it.... The auditors I've had the opportunity to work with didn't like it either - I've read articles both for and against the habit of "reverse level determination".  I tend to lean towards that "nay" side of it.  

I would agree however that documentation "alone" does not a level make - you could have 3 pages of dictation and it might still only be a level 2 or 3 or two paragraphs that will reflect a level 4 or 5!! It's what's "IN" the documentation, it's what exactly the doctor states and does that determines the level.  I've had sinusitis visits that were level 2 or 3, and some that are 4, it just depends on documentation and services provided. 

hey all - have a *MERRY* *CHRISTMAS!*


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## meganpoelzer (Jan 9, 2009)

Thank you so much to everybody for your input! I think it qualifies as a 99214 as well but wanted to see if anybody agrees. Sometimes coding can drive me nuts! Never boring!

Megan


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