In a recent transmittal from Medicare regarding the use of templets and documentation CMS stated that the overarching criteria for any visit level is Medical Necessity. This was repeated time and again through all of their examples and explanations.
How I explain this to my class is, that anyone can create a level 4 or level 5 document, but the real issue is SHOULD you have performed that level given the patient's medical necessity. There must be a match between the diagnosis and the visit level. Therefore if you are using the History and the MDM to set the level then how does that match up to the medical necessity. It could be entirely logical, and then again maybe not.