Define Medical necessity:
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.
Practice that is reporting a higher number of these 99233 and 99214 codes than their peers may
substantially increase their risk of audit and review. the CERT study gives the opportunity identify potential errors the same way that the auditor’s do.
This article focuses on the most common coding errors identified in the report to help you understand how to prevent them from occurring at your practice.
The key point to using 99233 is the provider must be sure to meet two of the three components:
• Detailed interval history
• Detailed examination
• High complexity Medical decision making (MDM)
Alternatively, they could spend 35 minutes or more of face-to-face time with the patient. Comorbidities and other underlying diseases cannot be considered when selecting 99233 unless their presence significantly increases the complexity of the medical decision making. Also if the provider chooses to use time to base the assignment of 99233, the time must be documented in the patient’s medical record and the documentation must have sufficient detail to justify the code selection.
Documentation Tips:
1. Documentation must be entered in a timely manner and must be decipherable to members of the healthcare team as well as other individuals who may need to review the information (e.g., auditors). Proper credit cannot be given for documentation that is difficult to read.
2.Information should include historical review of past/interim events, a physical exam, medical decision-making as related to the patient’s progress/response to intervention, and modification of the care plan (as necessary). The reason for the encounter should be evident to support the medical necessity of the service. Because various specialists may participate in patient care, documentation for each provider’s encounter should demonstrate personalized and non-duplicative care.
3.Each individual provider must exhibit a personal contribution to the case to prevent payors from viewing the documentation as overlapping and indistinguishable from care already provided by another physician. Each entry should be dated and signed with a legible identifier (i.e., signature with a printed name).
Consider Patient’s condition:
Neither guidelines provide fully objective, quantitative criteria by which medical necessity for an E/M Service may be judged. Understanding the medical necessity for ordering a lab or radiologic exam is comparatively easy:
Example: A provider orders a chest x-ray for suspected pneumonia, or serial troponins are ordered for chest pain to rule out acute coronary syndrome. Connecting the dots between a 99233 and medical necessity is not as clear.
Fortunately, CPT provides a clue in the full descriptor for CPT 99233. Usually, the patient is unstable or has developed a significant complication or new problem.
”Usually” statement referencing the stability of the patient
• 99231 “Usually, the patient is stable, recovering or improving.”
• 99232 “Usually, the patient is responding inadequately to therapy or has developed a minor complication.”
• 99233 “Usually, the patient is unstable or has developed a significant complication or a significant new problem
Based on these statements, it is the documented stability of the patient that determines the medical necessity of these subsequent care levels (when not billing based on time)
Differentiate between ”Significant” and ”Unstable”:
”Significant” and ”Unstable” these terms are not specifically defined, we can use Medicare’s 1995 and 1997 Documentation guidelines for E/M services to point us in the right direction—Specifically, the examples for a high level of risk under the presenting problem in the table of risk:
• One or more chronic illnesses with mild exacerbation, progression, or side effects of treatment.
• Acute or chronic illnesses or injuries that pose a threat to life or bodily function, e.g., multiple trauma, acute MI, pulmonary embolus, severe respiratory distress, progressive severe rheumatoid arthritis, psychiatric illness with potential threat to self or others, peritonitis, acute renal failure.
• An abrupt change in neurologic status, e.g., seizure, TIA, weakness, sensory loss.
For a new complication or problem to be considered “Significant” it should be comparable to the table of risk examples.
”Unstable” also follows this guideline, but for ongoing conditions rather than new problems or complications.
Example: A patient admitted yesterday for sepsis with respiratory failure and acute kidney injury, who today remains presents tachypnea and tachycardic, with worsening oxygen requirements and significantly elevated blood urea nitrogen (BUN), creatinine and lactate levels. Accounting for the presenting problems and the usually statements in the CPT and factoring in critical care, you can create a spectrum of patient stability that points to the medical necessity requirements for each subsequent care code level, as shown mentioned below table.
One condition documented as ”Improving” does not mean the patients overall condition is stable.
Time-based coding changes the Criteria:
The physician may document time spent with the patient in conjunction with the medical decision-making involved and a description of the coordination of care or counseling provided.
Documentation must be in sufficient detail to support the claim:
Physicians must document both the counseling/coordination of care time and total visit time. The format may vary: “Total visit time = 35 minutes; more than 50% spent counseling/coordinating care,” or “30 of 35 minutes spent counseling/coordinating care.” Any given payer may prefer one documentation style over another. It always is best to query payers and review their documentation standards to determine the local preference.
In addition to the time, physicians must document the medical decision-making and details of the counseling/coordination of care. For example, patients with newly diagnosed diabetes need to be educated about their condition, lifestyle, and medication requirements. Physicians should include information regarding these factors in their progress notes as necessary.
Note:
The Centers for Medicare and Medicaid Services (CMS) released the results from their Comprehensive Error Rate Testing (CERT) earlier this year. The results showed a 9.5% overall improper payment rate for 2017, representing $36.21 billion in improper payments.
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