tci Medicare Compliance & Reimbursement - 2012 Issue 24

Reader Question: Medical Decision Making Is Not The Same As Medical Necessity

Question: What should be the overarching factor you use to select the overall level of service for an E/M service? Answer: Medical necessity should always be the overarching factor used to select the E/M service level. Just because a physician completes a comprehensive history and examination doesn’t always mean he should report a level-five code. Medical necessity should always drive the components that he performs. Practices that try to exploit this loophole could be severely miscoding E/M levels. This mindset is particularly worrisome with the implementation of EHR systems, which often automatically code encounters without regard to medical...

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