Medical Necessity
I would refer them to the below reference. Medical necessity is the overarching criteria for the level of service. The chief complaint is what drives the medical necessity of the visit. I focus on the first column in the table of risk (presenting problems) which closely aligns with medical necessity when I am educating the providers. Below is the section in the Medicare Claims Processing Manual that I am referencing.
30.6 - Evaluation and Management Service Codes - General (Codes 99201 - 99499)
(Rev. 178, 05-14-04)
B3-15501-15501.1
30.6.1 - Selection of Level of Evaluation and Management Service
(Rev. 1875, Issued: 12-14-09, Effective: 01-01-10, Implementation: 01-04-10)
A. Use of CPT Codes
Advise physicians to use CPT codes (level 1 of HCPCS) to code physician services, including evaluation and management services. Medicare will pay for E/M services for specific non-physician practitioners (i.e., nurse practitioner (NP), clinical nurse specialist (CNS) and certified nurse midwife (CNM)) whose Medicare benefit permits them to bill these services. A physician assistant (PA) may also provide a physician service, however, the physician collaboration and general supervision rules as well as all billing rules apply to all the above non-physician practitioners. The service provided must be medically necessary and the service must be within the scope of practice for a non-physician practitioner in the State in which he/she practices. Do not pay for CPT evaluation and management codes billed by physical therapists in independent practice or by occupational therapists in independent practice.
Medical necessity of a service is the overarching criterion for payment in addition to the individual requirements of a CPT code. It would not be medically necessary or appropriate to bill a higher level of evaluation and management service when a lower level of service is warranted.
The volume of documentation should not be the primary influence upon which a specific level of service is billed. Documentation should support the level of service reported. The service should be documented during, or as soon as practicable after it is provided in order to maintain an accurate medical record.
B. Selection of Level of Evaluation and Management Service
Instruct physicians to select the code for the service based upon the content of the service. The duration of the visit is an ancillary factor and does not control the level of the service to be billed unless more than 50 percent of the face-to-face time (for non-inpatient services) or more than 50 percent of the floor time (for inpatient services) is spent providing counseling or coordination of care as described in subsection C. Medical necessity is still the overarching criteria on time based codes.
Ref.
Medicare Claims Processing Manual
Chapter 12 - Physicians/Nonphysician Practitioners
