Tovy I don't think you are understanding. It's not as if you can just write down "Saw Mr. Jones, his cancer has metastasized." and code that as a level 5 because of the medical necessity. The documentation must support the level 5... so that's why you need to count the key components (History, Exam, Medical Decision Making Complexity.)
What Deb is saying is that you can't just blindly count/score the key components and give a level of service. If it were that simple, a computer could do it. It would be quite easy for a provider who uses templated notes from an EMR to document a comprehensive history and comprehensive exam for every encounter. That does NOT mean they are all 99215's..... even though by definition you only need to meet 2 out of 3 components for that code range.
You need to consider the medical necessity. Was the extent of history and the extent of exam medically necessary and appropriate? Medical necessity is the overarching criterion for payment, so it can hold back the level of the code, but you cannot use it as a reason to increase the level of the code beyond what the documentation supports.
Now, be very careful with this concept.... we are NOT advizing you to start arbitrarily deciding what elements of the history or exam were not necessary. We are not clinicians, and we do not know what the physician is considering as a differential diagnosis. Just keep in mind that the code selection for a given level of service must be in line with the medical necessity. The CPT manual describes the typical nature of the presenting problem for each level:
99201- Typically, the presenting problem(s) are limited or self minor.
99202- Typically, the presenting problem(s) are of low to moderate severity.
99203- Typically, the presenting problem(s) are of moderate severity.
99204- Typically, the presenting problem(s) are of moderate to high severity.
99205- Typically, the presenting problem(s) are of moderate to high severity.
99212 - Typically, the presenting problem(s) are self limited or minor.
99213 - Typically, the presenting problem(s) are of low to moderate severity.
99214 - Typically, the presenting problem(s) are of moderate to high severity.
99215 - Typically, the presenting problem(s) are of moderate to high severity.