Documenting Medical Necessity

If you do a google search regarding medical necessity for E/M coding, you will find many articles, many experts referencing CMS guidance to Medicare payers in CMS’ Medicare Claims Processing Manual. The often referenced section is summarized as follows:

30.6.1 – Selection of Level of Evaluation and Management Service
(Rev. 3315, Issued: 08-06-15, Effective: 01-01-16, Implementation: 01-04-16)

A. Use of CPT Codes
…. The service provided must be medically necessary and the service must be within the scope of practice for a non-physician practitioner in the State in which he/she practices. …

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. Documentation should support the level of service reported. The service should be documented during, or as soon as practicable after it is provided in order to maintain an accurate medical record.

B. Selection of Level of Evaluation and Management Service
Instruct physicians to select the code for the service based upon the content of the service.

Here is the reference from the CMS’ Medicare Claims Processing Manual.

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From 1995 to 2020, many coding educators trained providers to document the 3 Key Components of history, exam, and medical decision making. These components provided some context to document medical necessity when used appropriately.

With the activation of the 2021 EM Outpatient coding changes as of January 1, 2021, clearly documenting the medical necessity of an outpatient E/M visit is just as important. We have heard from clinicians that the 2021 EM coding guidelines will be more familiar and consistent with the way they practice.

However, many EMR records now carry ICD-10 codes for MIPS purposes and to “tell the story” of the health of the patient. Though a provider may not be managing all of the conditions, some conditions outside of their care may enter into the risk and complexity of the conditions the provider is managing.

The new 2021 E/M Guidelines focus on medical decision making as it relates to the care the provider is providing to the patient’s condition(s). Providers will need to document to support billing, as well as to be clear if reviewed by an outside reviewer in the future.

Here are some thoughts to consider.

How are you training your providers to clearly document what is to be billed and what conditions, though not billed, impact the risk and complexity of the provider’s care of the patient?

Does your encounter note clearly delineate between notes taken by MA for non-billed ICD-10s, and notes by the provider referring to conditions that impact the management of patient care?

Should I use Data to be Reviewed and Analyzed: Minimal or None?

This week’s question: “Could you please explain what the Minimal Data to be Reviewed check box would be used for? In what instances would we use this?”

The AMA’s Data to be Reviewed and Analyzed column lists “Minimal or none”  as part of the definition for a Straightforward MDM.

A Straightfoward MDM defines the lowest E/M code level a provider will be coded – an E/M code “level 2” – 99202 or 99212.

Whatever “cheat sheet,” software, checklist you are using, coding an E/M code using “no data reviewed or analyzed” seems counter intuitive and may be difficult to defend.

If we look at the pre-2021 (1995 / 1997) MDM’s Data to be Reviewed and Analyzed – it also lists tests, old records, external sources, etc.

AMA – E/M Office Visit 2021

Slides 50 says

MDM: Amount and/or Complexity of Data to be Reviewed and Analyzed

• Simplified and standardized contractor scoring guidelines

• Emphasized clinically important activities over number of documents

• Need to account for quantity of documents ordered/reviewed (as it is MDM work)

Note that the goal for the Data to be Reviewed and Analyzed section is meant to quantify its impact on the effort in medical decision making (“it is MDM work”).

As we’ve highlighted in prior articles, having a definition for 99202 or 99212 and/or asking providers to document for complexity of diagnosis and risk of morbidity would provide a more compliant process to bill for any E/M code.

With a “grey area” such as Data To be Reviewed minimal or none, how providers are trained to document will need to be defensible in a retrospective audit review. It is best to document the methods and definitions your organization defines in your standard operating procedures.

Using Time to determine an Outpatient E/M code

Our goal in this blog series is to encourage conversation regarding open topics in the 2021 E/M Guidelines. We’re hoping to help bring clarity, to provide scenarios for your consideration, and to help you educate your providers.

The previous E/M Guidelines stated that Time may only be used when counseling and/or coordination of care dominates the service.

As of January 1, 2021, the AMA has provided new definitions on using Time to determine an E/M code. 

The 2021 AMA CPT^(R) Manual states: 

“For coding purposes, time for these services is the total time on the date of the encounter. It includes both the face-to-face and non-face-to-face tie personally spent by the physician and/or other qualified health care professional(s) on the day of the encounter (includes time in activities that require the physician or other qualified health care professional and does not include time in activities normally performed by clinical staff).”

The exception is 99211. Per the AMA, “the time component has been removed” for 99211. The time to supervise clinical staff is not measured. The CPT^(R) Manual states “… if the physician’s or other qualified health care professional’s time is spent in the supervision of clinical staff who perform the face-to-face services of the encounter, use 99211.”

Although using Time to code an E/M would seem to be a welcomed change, industry thought leaders are asking “how will practices justify the E/M code billed based on Time when medical necessity is the “overarching criterion” for coding an E/M service?”

Here are the conditions outlined in the 2021 CPT^(R) Manual. Bold font is our device to call attention to specific definitions. 

Expanded definition

• includes both the face-to-face and non-face to-face time

Specific timing

• on the day of the encounter

Specific qualifications

• personally spent by the physician and/or other qualified health care professional(s)
• (includes time in activities that require the physician or other qualified health care professional
• and does not include time in activities normally performed by clinical staff ).

AMA’s 2021 CPT^(R) Manual lists nine activities that can be included in defining the Total Time spent in caring for a patient. Note that these activities cover pre-encounter, intra-encounter, and post-encounter activities.

As our audit experts recommend, remember to document the medical necessity for the encounter. Also, remember that Total Time for the provider’s day should be reasonable. If an auditor were to add up all the time billed, would the total time for the day be physically possible? As we’ve noted in a prior post, auditors are looking for “potential fraud, such as claims development and submission processes, code gaming … “

In your education and planning for coding Outpatient EMs for dates of service in 2021, under what scenarios will you use Time to bill an Outpatient E/M code?

What documentation will you train your providers to do to communicate the medical necessity?

Column 3 of the 2021 E/M “Grid”

In the prior two posts we discussed “column 2”, Data To Be Reviewed and Analyzed. For coders, this may seem to be a straightforward way to add up “points.” However, using the Data To Be Reviewed and Analyzed column may cause more questions given the complexities in everyday life in a healthcare practice. 

For example, a question we recently received was “How do I count a test discussed but refused by the patient?”

Have you considered the 3rd column of AMA’s 2021 E/M “grid” ?  

Column 3 defines the Risk of Complications and/or Morbidity or Mortality of Patient Management.

The levels for this section describe the Risk of morbidity or mortality from additional diagnostic testing or treatment as Minimal, Low, Moderate, or High risk.

The definitions in the 2021 AMA CPT^(R) manual says:

The risk of complications and/or morbidity or mortality of patient management decisions made at the visit, associated with the patient’s problem(s), the diagnostic procedure(s), treatment(s). This includes the possible management options selected and those considered but not selected, after shared MDM with the patient and/or family.

Shared MDM involves eliciting patient and/or family preferences, patient and/or family education, and explaining risks and benefits of management options.

Column 3 may be more “clinically relevant” to your providers.

As described in an AMA article, How 2021 E/M coding changes will reshape the physician note, written Nov. 6, 2020 by Senior News Writer, Andis Robeznieks, the 2021 E/M changes were intended to encourage the documentation of what was clinically important.  

He quotes Barbara Levy, MD, former chair of the AMA/Specialty Society RVS Update Committee (RUC) and co-chair of the AMA-convened workgroup responsible for the coding overhaul, from her summary of the Outpatient E/M codes changes for 2021.

“It’s either medical decision-making or it’s total time on the date of the service and it’s only including those things that are medically necessary for the treatment of the patient,“.

“Hallelujah! We’re getting back to what’s clinically relevant and what matters for us and our patients,” 

Mr. Robeznieks further quotes Dr. Levy as saying the risk of complications or morbidity component is about “what’s going on with this patient,” 

This clinical understanding is also stated on page 14 of the 2021 AMA CPT^(R) manual. It states:

“Definitions of risk are based upon the usual behavior and thought processes of a physician or other qualified health care professional in the same specialty. Trained clinicians apply common language usage meanings to terms such as high, medium, low, or minimal risk and do not require quantification for these definitions (though quantification may be provided when evidence-based medicine has established probabilities).”

Given this change to the E/M documentation guidelines, it might be beneficial to talk with your providers about how to shape their notes to clearly document the patient management risk(s) for clinical and coding purposes.

One of our expert auditors, Jill Young, CEMA, CPC, CEDC, CIMC has suggested that a narrative note could be very effective.

Might this strategy help your practice?

Tracking and crediting “unique test(s)”

Our goal in this blog series is to provide a forum regarding topics around the upcoming 2021 E/M Guidelines, to encourage community conversation on how the new guidelines might be applied. In our last post we talked about crediting the ordering and review of a test only once.

Considerations for crediting tests in Amount and/or Complexity of Data to be Reviewed and Analyzed > Category 1: Tests and documents section of the MDM grid to determine your E/M services

You may be reading various articles and attending training sessions which have led to the decision to credit “unique test(s)” when ordered during an encounter.

What if additional tests are ordered between encounters?

In this case, tests not credited in the prior encounter can be credited in the subsequent encounter.  To realize these orders, the series of encounters or dates of orders would need to be tracked.

Jill Young, CEMA, CPC, CEDC, CIMC recommends the following. To take credit for reviewing a test ordered between appointments, the easiest way is to show it in your documentation. For example, “Chest xray ordered on January 1, 2021 showed — ” or “Labs reviewed ordered on January 1, 2021 showed.” This dating should prompt any reviewer to look at visit dates and see the orders were in between encounters. Otherwise, you would rely on the reviewer to do the extra work of looking at the series of patient encounters and noting the dates of the last one and comparing it to the date of the test ordered.

Does your practice see a significant amount of test ordering between encounters?

If tests are often ordered between encounters, will your EMR track and highlight these tests to be credited in the next encounter?

When credited towards an E/M service, will it be obvious in the documentation for retrospective audits?

The Amount and/or Complexity of Data to be Reviewed and Analyzed column of the 2021 MDM grid may cause questions as coders and auditors start to apply it to the varied scenarios you see every day. We are hearing these questions from our customers.  

Keep Calm. There will be grey areas.

As several websites are reporting, you will encounter “grey areas” as you implement the 2021 E/M Outpatient coding guidelines in your organization. As with the E/M Guidelines since 1995, the recommendation by compliance experts is to create internal policies based on your interpretation of guidelines, and follow them consistently within your organization.

As stated by the U.S. Department of Health and Human Services Office of Inspector General (OIG), at “… a minimum, comprehensive compliance programs should include…the development and distribution of written standards of conduct, as well as written policies and procedures that promote the [organization’s] commitment to compliance and that address specific areas of potential fraud, such as claims development and submission processes, code gaming, and financial relationships with physicians and other health care professionals.”

Though the intent of the 2021 E/M Changes was to “reduce administrative burden”, sufficient documentation of the E/M service provided is still relevant. Documenting how you will handle the “grey areas” will help provide consistency and clarity long after the services were provided.

The OIG’s Compliance Program for Individual and Small Group Physician Practices states: “The physician practice written standards and procedures concerning proper coding reflect the current reimbursement principles set forth in applicable statutes, regulations ²¹ and Federal, State or private payor health care program requirements and should be developed in tandem with coding and billing standards used in the physician practice. Furthermore, written standards and procedures should ensure that coding and billing are based on medical record documentation. Particular attention should be paid to issues of appropriate diagnosis codes and individual Medicare Part B claims (including documentation guidelines for evaluation and management services).²²“

Let’s learn together.

We hope you’ll share your thoughts with us!