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Documentation and Level of Service - Evaluation and Management Services

Medical Review Level of Service Findings

The Noridian Part B Medical Review (MR) Department has noticed, during prepayment medical review, the provider community is using a quantification method to code their claims. The amount of data contained in the medical record should not be the controlling factor for determining the level of service (LOS). It is neither acceptable nor appropriate to include additional information in the medical record for the sole purpose of meeting the billing requirements for a specific Current Procedural Terminology (CPT) ® code. Providers may include any and all data that they deem appropriate in their patient's notes. However, per Medicare regulations, providers are required to bill only for the elements that are medically reasonable and necessary for the treatment of the patient.

Noridian Part B MR is aware that providers and/or ancillary staff use worksheets when coding E&M services. These worksheets often award "points" to the three major components of an E&M service which are History of Presenting Illness (HPI), Physical Exam, and Medical Decision Making (MDM). The use of a "points" system thus quantifies a service.

For any E&M CPT code that contains a descriptor of "established" or "subsequent" patient, CPT requires the documentation meet or exceeds two of the three key components listed above. A descriptor of "new" or "initial" patient requires three of three key components to be met or exceeded.

When determining the LOS for the HPI using a points system, a full Past Family Social History (PFSH) could in fact up' the level of HPI. However, to get credit for PFSH, the histories documented need to be pertinent to the date of service in question and applicable to the medical management of that particular patient on that particular day.

Noridian Part B MR has also noticed that providers are crediting themselves for a list of diagnosis codes and/or medications included in the HPI when determining LOS. While it is appropriate to document the patients past medical history (PMH) and list of current medications, it is not appropriate to have those elements taken into consideration determining the level of a key E&M category.

When reviewing documentation to support the LOS for a "new" patient or "initial" visit, Part B MR is finding that the documentation does not meet three of three key components and a large percentage of claims are correct coded to a lower level of service. The higher the CPT level, the more increasingly difficult it can become to meet the LOS defined by CPT and be medically reasonable and necessary.

Time Based Services

While some CPT codes allow the LOS to be time based, it is not acceptable to simply state "35 minutes spent with patient discussing treatment." When counseling and/or coordination of care is the key factor is determining LOS, documentation needs to support the amount of time spent in discussion and detail the context of the conversation and any decisions made or actions that will result based on this counseling. Per CPT, time can be used as the controlling factor for LOS when the counseling and/or coordination consume at least 50% of the total office visit. Refer to the article titled "Evaluation and Management: Time" located in CPT Assistant Volume 10, Issue 12, December 2000. This article has extensive information regarding the elements required when billing based on time.

Domiciliary, Rest Home, or Custodial Care Services

A trend noted by Part B MR is the frequency of claim submissions for CPT® 99334-99337. It appears that providers who make house calls' are seeing patients at an interval to mirror that of a Skilled Nursing Home (SNF) patient. While there are federal regulations that govern how often a patient in a SNF needs to be evaluated by a Physician or Non Physician Practitioner (NPP), Part B MR is unaware of regulations governing how often a patient needs to be evaluated in the context of CPT® 99334-99337.

Documenting the Medical Necessity for the Visit

A vast majority of the documentation submitted to support claims billed with CPT® 99334-99337 fails to establish the medical necessity of the service. The documentation does not support any active issues or new injuries, and does not support any changes to the plan of care and/or medications. The documentation essentially supports a routine visit by the physician. The burden of proof for medical necessity of the service is that of the provider. Claims will be denied as not medically reasonable and necessary when the person who renders the service fails to document the medical necessity of the service.

Another trend noted by Part B MR is the MDM does not correlate to the chief complaint. One such example would be the HPI supports a follow-up visit for renal functions tests, hypertension, and reflux. The medical management of that patient is then a Physical Therapy referral for low back pain, with no mention of medical management of the issues that brought the patient to the clinic. The documentation did not support complaints of low back pain. Part B MR has also noted that the plan of care simply lists the medical diagnoses of the patient, with no mention of changes to the plan of care if any, or continuation of current treatment regimens. It is difficult to determine the medical necessity of a visit when the documentation lacks important information, or when the documentation does not support medical management of the patient's chief complaint.

Medical Review Documentation Findings

Noridian Part B MR has noticed that many patient records submitted for review contains nonsensical and/or incomplete documentation, suggesting that they have not been reviewed by the provider at the time of preparation or prior to submission upon the contractor's request. Medical notes must be comprehensible and legible. The primary purpose of medical documentation is to ensure that the patient's treatment is recorded for the continuity of appropriate treatment by the attending provider(s). It is also important for colleagues, consultants, and office staff as well as other third parties that the notes are written legibly or are typed. Nonsensical and/or incomplete documentation increases the potential of legal implications for a provider.

Credit for services rendered cannot be granted if the medical record is incomplete. Additionally, the use of some software programs produces office notes that are nonsensical. Below are some examples of office notes submitted for medical review containing incomplete and/or nonsensical documentation.

  1. Excerpt from exam portion of E&M: "His liver alert and oriented x3 shows a deficit of cognitive function are thought physical psychosomatic eye pupils equal and rectal exams are normal her eczema with inflammation".
  2. Excerpt from HPI portion of E&M: "She states her back is doing much better she's and Lipitor she has no hip or bone pain which has an infected tooth mesh for which she is on penicillin (Augmentin) as well as chlorhexidine mouth wash there thinking it may be due partially to the radio which she's not had a shot for some time now"
  3. Excerpt from HPI: "She has insomnia-she takes her temazepam at HS-she is gestating at least 5 hours at night"
  4. Excerpt from HPI: " He i s needing a letter for his Shuttle service-he is needing it-he is wheelchair borne-he has weakness of the"
  5. Excerpt from HPI: "She is here waiting for her schedule to see Dr. X (cardiology) for her heart and her ankle edema which is scheduled on March 30th. He has been causing apnea-with Dr. Y soon as well."
  6. Excerpt from HPI: "He still lives alone and cooks for himself. He gets his meds prepared weekly for him at Nicholson's"

In the first two examples listed above, it is very hard to tell what exam items to give credit to for this patient. When notes are provided with no punctuation the thought process is hard to follow. Notes must be proofread before your electronic signature is applied. Signatures are verifying the notes are accurate, complete and without omission.

Documentation Software Templates

Noridian Part B MR has noted that some Electronic Medical Record (EMR) software programs auto-populate certain aspects of the medical record with information that is not patient specific. This issue is more profound in the HPI when discussing the context of a certain illness and/or co-morbidity. Documentation to support services rendered needs to be patient specific and date of service specific. These auto-populated paragraphs provide useful information such as the etiology, standards of practice, and general goals of a particular diagnosis. However, they are generalizations and do not support medically necessary information that correlates to the management of the particular patient. Part B MR is seeing the same auto-populated paragraphs in the HPI's of different patients. Credit cannot be granted for information that is not patient specific and date of service specific.

Medical Necessity

Per the Internet Only Manual (IOM) Medicare Claims Processing Manual, Publication 100-04, Chapter 12, Section 30.6.1 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. Documentation should support the level of service reported."

Furthermore, all services must be sufficiently documented so the medical necessity is clearly evident. Medicare cannot pay for services for which the documentation does not establish the medical necessity. Section 1862(a)(1)(A) of Title XVIII of the Social Security Act provides "&no payment may be made under Part A or B (of Medicare) for any expense incurred for items or services which&are not reasonable and necessary for the diagnosis or treatment of illness or injury or to improve the functioning of a malformed body member".

Services rendered should be billed to Medicare based on the medical necessity of the visit. If the visit does not necessitate the detail of documentation required to meet CPT code 99XXX a lower level of service should be billed. Do not include additional components in the record for the sole purpose of meeting a specific CPT code.

Medical necessity cannot be quantified using a points system. Determining the medically necessary LOS involves many factors and is not the same from patient to patient and day to day. Medical necessity is determined through a culmination of vital factors, including, but not limited to:

  • Clinical judgment
  • Standards of practice
  • Why the patient needs to be seen (chief complaint),
  • Any acute exacerbations/onsets of medical conditions or injuries,
  • The stability/acuity of the patient,
  • Multiple medical co-morbidities,
  • And the management of the patient for that specific DOS.

Education and Publications

CMS offers a variety of tools to assist providers in determining the level of service for E&M services. The CMS website has the following publications available:

Other publications to assist with coding and determining the level of service are

  • Current Procedural Terminology® (CPT)
  • National Correct Coding Initiative (NCCI)

While the publications listed above are available for documentation and/or coding assistance, they are strictly guidelines, and do not provide a definitive answer to determine the level of service for E&M claims.

Noridian Part B MR reminds providers that the coding of services submitted to Medicare is ultimately the responsibility of the service provider. Regardless of a separate entity coding and/or submitting the claims, the provider who rendered the services is held accountable for the level of service billed.

Noridian Part B MR also reminds providers that the medical necessity of laboratory tests and/or radiological testing needs to be clearly stated in the medical record. Often the medical record fails to establish the medical necessity of a lab order. Without the rationale clearly indicated in the medical record, the service becomes not medically reasonable and necessary, and thus denied.

Last Updated Jul 16, 2015