Why it is Necessary to Demonstrate Medical Necessity

Some physicians and coders believe that CPT guidelines allow for reporting 99215 for any established patient based on a comprehensive history and examination, even if the MDM is low risk. By this reasoning, you may report 99215 for any E/M visit where the physician documents a comprehensive physical and exam, even if he or she only treats a minor problem. However, this is a myth. CPT E/M guidelines do not offer a legal loophole allowing them to ignore medical necessity.

The nature of the problem for which the patient presents is the measure of medical necessity for E/M services. This is included for every level of service. If medical necessity is not evident in documentation, then the charge could possibly be downcoded and would be considered abusive behavior.

The history, exam, and MDM performed must be relevant to the presenting problem(s). An Auditor will look at any billed E/M services against the medical necessity, so the documentation will have to speak for itself. An unusually high number of upper level services will draw the attention of the payer. If a physician bills all 99214’s and 99215’s, that is a red flag for the insurer. Carriers use data by specialty to target practices for audits. If the majority of your E/M services are billed at higher levels, then your data will be above the norm.

The length of time that the physician spends with the patient can help quantify medical necessity for visits. The CPT states that 99214 or 99215 usually require 25 or 40 minutes of time respectively. Obviously, physicians don’t spend this much time treating minor problems.

View all Articles by: Kathryn Etienne, CCS-P