Nature of the Presenting Problem

How is Medical Necessity Factored Along with Nature of the Presenting Problem?

Do you wish CMS would streamline the Evaluation and Management (“E/M”) guidelines so that everything is black and white?  If so, you are not alone……

The E/M guidelines are just that, GUIDELINES! They serve as a resource when determining the level of care provided for visit.  However, they are not the only source to consider in leveling an E/M Current Procedural Terminology’ (“CPT”) code.

Additional resources include, but are not limited to:

AMA CPT Book Section and Category Notes

• Nature of the presenting problem: The E/M codes recognize five types of presenting problems (minimal, self-limited, or minor, low severity, moderate severity and high severity).
• Under each E/M CPT there is a description of the presenting problem severity level.
  • Example: 99213 – “usually the presenting problem(s) are of low to moderate severity”. Whereas, CPT code 99214 states, “the presenting problem(s) are of moderate to high severity.”

• Clinical Examples, Appendix C
  • 99213 – “follow up established patient office visit for stable cirrhosis of the liver in a 62-year-old patient.”
  • 99214 – “established patient office visit for a 32-year-old with new complaint of right lower quadrant pain.”

• Medicare Claims Processing Manual (Pub 100-04), chapter 12, section 30.6.1, Selection of Level of Evaluation and Management Service states:
  • “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.”

Keep in mind… Medicare will deny or down code services
exceeding the patient’s documented medical need!

Medical Decision Making (“MDM”) is not necessarily a required key component for established patient visits (99212-99215) or subsequent hospital visits (99231-99233), since these levels of service only require two (2) of the three (3) key components (history, exam, medical decision making).  Some practices and organizations set internal protocols requiring medical decision making as a mandatory component for all E/Ms.  While using the MDM as a required element in leveling the E/M is not required, the protocol provides a more direct approach for providers and coders when selecting the E/M level. Using this protocol as a standard, also allow the organization’s coder/auditors to follow the same requirement for consistency in monitoring for compliance with clear expectations.  Keep in mind however, if an organization does implement such a requirement, they may lose out on revenue when the visit is appropriately supported on some occasions by the other two (2) elements when only two (2) out of three (3) are required, but they may make up the lost revenue with reducing the larger risk of overcoding levels inappropriately.

With the implementation of savvy Electronic Health Record Systems (“EHRs”), overdocumentation can easily be an issue.  Templates, copy & paste or copy forward techniques can cause headaches for the coder/auditor when MDM is not one of the two (2) of three (3) organization required key components.

When coding and/or auditing, it helps to keep these core questions in mind:

• What truly happened at the visit today?
• Is the information documented in the subjective paragraph Past Medical History or History of Present Illness?
• What information is truly pertinent to today’s visit?

Medicare and its Contractors have adopted Program Integrity Practices to address vulnerabilities in EHRs.

For example, copy-pasting information from visit to visit results in repetitious information over time.  Not all the information may be needed or correct or even applicable to the current visit.  Over time notes can result in making it difficult or impossible to identify the unique information on the date of service.  When payors review supporting documentation and identify these documentation (note cloning patterns) the organization could see denials or additional audits questioning the medical necessity of many visits.  Often, information carried forward, especially if the user fails to update it or ensure it’s accuracy conflicting information also results causing even more risk to everyone.

Overdocumentation is another example of EHR vulnerability. EHRs can auto-populate fields when using time-saving templates. They can generate unnecessary documentation from a single click. Such features can produce information suggesting the provider performed elements they did not or a more comprehensive service than performed or what would even be deemed medically necessary if the claim came fell under scrutiny.

To safeguard against assigning a level of service higher than what may be deemed medically necessary, implement policies and procedures surrounding EHR functionalities such as:

1. Templates cueing users for information without prepopulating
2. Responsible use of copy and paste, or prohibiting its use
3. Requiring MDM drive all E/M levels
4. Identifying and validating the nature of the presenting problem supports all E/M levels assigned
5. Develop an auditing and monitoring program to review documentation and code assignment
6. Utilize resources such as Bell Curve Analysis and/or CMS data reports to track trends for all providers

And remember, if you need assistance in preparing internal coding protocols with a systematic approach, Pinnacle is here to help!