Let's Talk High Risk E/M Services

by  Aimee L. Wilcox, CPMA, CCS-P, CST, MA, MT
Apr 23rd, 2019

Have you ever assigned a high-complexity E/M code (e.g., 99205, 99215, 99223, 99233, 99245, etc.) and wondered if it would stand up to further scrutiny? Well, let’s take a closer look at the requirements for reporting high-level E/M services.  

Both the American Medical Association and Medicare-published E/M Guidelines agree that a high level of complexity and medical necessity must be supported in the medical record to report a high-level E/M service. This may be accomplished in one of two ways: 

1. Component scoring & medical necessity
2. Time & medical necessity 

Component Scoring

Component scoring requirements for a new patient (NP) differs from those of an established patient (EP), in that NPs require criteria from all three key components to be met while only two of the three must be met for an EP. Both, however, require the same high-level medical necessity. 

Component requirements include:

• Comprehensive history
• Comprehensive examination 
• High-complexity medical decision making (MDM)
  • Extensive diagnoses or management options 
  • Extensive amount and/or complexity of data to be reviewed
  • High risk of complications and/or morbidity or mortality

Find-A-Code subscribers can see the details of what is required in component scoring by using our E/M Calculator. Nonsubscribers can also use the E/M Calculator by signing up for a free trial, which will allow you to use the many fabulous tools available to you for 28 days, without any additional obligation to purchase.

Time

Determining the highest level of E/M based on time depends on the E/M category the service falls into and medical necessity.

Determining the E/M level based on time requires the provider document the total face-to-face time spent counseling and coordinating care with the patient, a summary of what was counseled and coordinated, and specifying that more than 50% of the total face-to-face time spent with the provider was actually used for counseling and coordinating this care. 

Some examples of what might be considered high-complexity could include (but are not limited to): 

• Recommendation of complex, high risk, or emergency surgery where the risks, complications, and alternatives are discussed and reviewed with the patient
• Decisions for palliative or hospice care for end-of-life situations
• Discussion about treatment options or recommendations for severely exacerbated or progressively worsening conditions, or treatments that are causing severe or risky side effects in a patient with one or more chronic conditions
• A decision to place the patient on high-risk medications that require intensive toxicity monitoring or drug screens
• Acute or chronic illnesses that are posing a threat to the patient's life or organ system function that need immediate attention and counseling or coordination of care

As you can see by the information provided, when considering assignation of a high-complexity E/M service, the documentation really needs to paint a picture of a patient who is in a serious situation with their health due to acutely severe or chronically exacerbated conditions. 

Medical Necessity

The other half of MDM and Time is identifying whether or not the documentation supports medical necessity. It may seem as if medical necessity is difficult to assess, and in some cases, it may very well be; however, once again, the Table of Risk helps to clarify what patient conditions or circumstances not only warrant a high level of E/M service but also support it. Providers can always improve their documentation, especially when it comes to reporting high-level E/M services, by including the specific risks to the patient (not all patients, but the particular patient for whom they are making medical decisions). Also, including any complicating factors, like comorbidities currently exacerbating the problem or complicating decision making for this encounter, why urgent or complex treatment is required, and of course, if surgery is needed promptly, why and the risk to the patient by undergoing surgery or opting to postpone it help to establish medical necessity.

Documenting the details allow reviewers to quickly identify medical necessity for the decision making taking place and the high-level E/M service being reported. 

About Aimee L. Wilcox, CPMA, CCS-P, CST, MA, MT

Aimee L. Wilcox is a medical coding, billing, and auditing consultant, author, and educator with more than 30 years of clinical and administrative experience in healthcare, coding, billing, and auditing. Medicine, including coding and billing, is a constantly changing field full of challenges and learning and she loves both. Aimee believes there are talented medical professionals who, with proper training and excellent information, can continue to practice the art of healing while feeling secure in their billing and reimbursement for such care.