• Chronic Care Management (CCM)
• Documentation and Level of Service
• Evaluation and Management Clarification

Guideline Differences Between 1995 and 1997

E/M Components	History: History of Present Illness	History: Review of Systems	History: Past, Family and Social	Exam	Decision Making
1995	No Difference - An extended History of Present Illness may consist of status of three chronic/inactive conditions for either set of guidelines (1995 or 1997) for services performed on/after 09/10/13.	No Difference	No Difference	Body areas, body systems or complete single organ system	No Difference
1997				General multi-system or single organ system

 

The following is an excerpt from the CMS Internet Only Manual (IOM) Medicare Claims Processing Manual, Publication 100-04, Chapter 12, Section 30.6.1,

"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 level of service (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.

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.

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.

The medical necessity of laboratory tests and/or radiological testing needs to be clearly stated in the medical record. Noridian has found 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.

Resources

• CMS Medicare Learning Network (MLN) Matters (MM)7405  - Clarification of Evaluation and Management (E/M) Payment Policy 
• CMS MM6698 - Signature Guidelines for Medical Review
• CMS Internet Only Manual (IOM), Publication 100-04, Medicare Claims Processing Manual, Chapter 12, Physicians/Nonphysician Practitioners