Stop Using the 'Loophole' to Bill 99215
Published on Sat Jul 21, 2007
CPT and CMS require medical necessity for all E/M visits If you are a victim of the "E/M loophole" myth, you could be severely miscoding your E/M levels and collecting thousands more in payment than you deserve -- and that could lead to dire consequences down the line.
MDM Matters Most, CMS Says
The argument: Some physicians and coders reason that CPT guidelines allow reporting 99215 for an established patient based on a "comprehensive" history and a "comprehensive" examination, even if the medical decision-making (MDM) is low risk and there is no data to review.
Therefore, the argument goes, you may report 99215 for any E/M visits during which the physician documents a comprehensive physical and exam, even if the physician treats a minor problem.
The big question: Do the CPT E/M guidelines offer physicians a legal "loophole" by allowing them to ignore medical necessity?
The answer: "Absolutely not," says Stephen R. Levinson, MD, author of the AMA's Practical E/M: Documentation and Coding Solutions for Quality Health Care. CMS guidelines explicitly state, "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," Levinson says, "and this important contributory factor is included for every level of every type of service that measures care using the three key components. Additionally, the Clinical Examples in Appendix C of CPT have been developed anapproved by our own specialty societies to illustrate the level of care warranted by representative patient problems, and CPT directly tells us that the clinical examples" are provided to guide physicians in understanding the descriptors' meanings and selecting the correct code.
"CPT says that for established patients, only two out of the three components need to be met to code the service. However, there is a big overriding factor -- medical necessity," says Suzan Hvizdash, BS, CPC, CPC-EMS, CPC-EDS, physician education specialist for the department of surgery UPMC Presbyterian-Shadyside in Pittsburgh.
"If medical necessity is not evident in the documentation, the charge could be downcoded," Hvizdash says. This could cause the insurer to request a repayment.
History Must Be Relevant
If your pulmonologist still balks at coding simple, uninvolved visits using 99212 or 99213, refer him to the E/M documentation guidelines, which make several references to medical necessity, says Erica D. Schwalm, CPC-GSS, CMRS, billing and coding educator in Springfield, Mass. Schwalm refers to the following references from the 1995 E/M guidelines:
1. Must have: "The documentation of each patient encounter should include: reason for the encounter and relevant history, physical examination findings and prior diagnostic test results."
The key word here is "relevant‚" Schwalm says. "If the patient presented with a runny nose, a comprehensive history and exam [...]
