Oncology & Hematology Coding Alert

Question: What do E/M codes mean when they say you only need two of three components?

Texas Subscriber Answer: When an E/M code descriptor says a code requires at least two of the three key components, you can drop the lowest element and use the other two to drive your code choice.

Example: If you have a detailed history, a comprehensive exam and high-complexity medical decision-making (MDM) for an established patient visit, you can eliminate the lowest (detailed history), and the other two elements indicate that 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 -) is the appropriate code.

Protect yourself: If the presenting problem won't support a high-level E/M service, you can't get paid for the service just because the physician documented a comprehensive history and exam and high-complexity MDM. Medical necessity is the overriding umbrella that should determine the service level.

When an E/M code instead says that you must meet all three key components, you must base your code selection on the lowest element.

Example: If you have a detailed history, a comprehensive exam, and high-complexity decision-making for a consultation, you have to base your decision on the lowest element (detailed exam), making 99243 (Office consultation for a new or established patient, which requires these three key components: a detailed history, a detailed examination, and medical decision-making of low complexity -) the appropriate code.

Again, the service must meet the medical-necessity requirement.

Typically, new patients or initial visits require all three components, and established or subsequent visits require just two, but don't make assumptions. Each code description will tell you how many you need.