tci E/M Coding Alert - 2013 Issue 2

Reader Question: Extensive Documentation Does Not Automatically Warrant Level 5

Question: Our physician is an amazing documenter — for established patients (which only require two of the three elements required for a particular E/M code), he almost always qualifies for 99215 even if he’s just doing a medication refill. He wants to know what should be the main factor he should use to select the overall level of service for an E/M service? Ohio Subscriber Answer: Medical necessity should always be the overarching factor used to select the E/M service level, which CMS has reiterated several times, including in Transmittal 178 (www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/downloads/r178cp.pdf). Just because a...

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