Squeezing Through E/M 'Loophole' Could Create Trouble on Claims
Published on Mon Jan 08, 2007
Here's why coding 99215 regardless of medical necessity could cost you Coders, beware: Some physicians believe that when coding E/M services for established patients, there is a loophole that allows level-five reporting regardless of the medical necessity of the encounter. Practices that try to exploit this loophole myth could be severely miscoding E/M levels.
Common misconception: Some physicians interpret E/M rules to mean that they can report a level-five E/M based on history and examination if they can substantiate in the record that they performed a comprehensive history and examination on this patient -- even though the medical decision-making (MDM) is low complexity.
Therefore, the physician thinks she is entitled to bill 99215 (Office or other outpatient visit for the evaluation and management of an established patient, which requires at least two of these three key components: a comprehensive history; a comprehensive examination; medical decision-making of high complexity) for any E/M visits during which she performs a comprehensive physical and exam, even if she treats a patient with a mild headache.
So the question is: Do the E/M guidelines offer physicians a legal -loophole- by allowing them to ignore medical necessity?
-Absolutely not,- says Stephen R. Levinson, MD, author of the AMA's Practical E/M: Documentation and Coding Solutions for Quality Health Care.
-CMS indicates in its Carriers- Manual that -Medical necessity is the overarching criterion for payment in addition to the individual requirements of a CPT code.- The nature of the presenting problem is CPT's measure of medical necessity for E/M services, and this factor is included for every level and every type of service that measures care using the three key components,- he says.
Explore the Origins of This -Loophole- Some coders may wonder why physicians use what could be called a loophole. -It's not really a loophole as much as it is a code definition,- says Suzan Hvizdash, CPC, CPC-EMS, CPC-EDS, physician education specialist for the department of surgery UPMC Presbyterian-Shadyside in Pittsburgh. -In CPT it says that on established patients, only two out of the three components need to be met in order to code the service. However, there is a big overriding factor -- medical necessity.
-If medical necessity is not evident in the documentation,- Hvizdash says, -the charge could be downcoded and would be considered abusive behavior.-
So when would the neurosurgeon perform comprehensive history and exam without sufficient medical necessity for 99215? -It could be that the patient came in for a chronic and self-limiting diagnosis; it could also be a case where the physician felt as if he was performing a service of high complexity, but did not dictate all of the indications in detail,- says Margaret Mize, CPC, coder at Birmingham Neurosurgery & Spine Group in Alabama.
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