Q: Our providers are confused about medical necessity. Some say it applies to time-based coding. Others say medical necessity only applies when you code based on the visit components, including medical decision-making. Who’s correct?
A: The term medical necessity appears in different ways in various Medicare materials. It has at least two meanings or versions.
When talking about a code 99215 based on the components of history, exam, and medical decision-making, medical necessity is typically regarded as a part of medical decision-making component. That includes an evaluation of how sick the patient is, the complexity of the management process, or whether it qualifies for high level decision-making. And that's where we use the decision-making tables: data, risk, nature of problems, and so forth. That is how a visit without time is measured.
Medicare requires that level of detail when a provider documents they spent “More than half of the 40-minute visit counseling the patient on x, y, and z.” See the following excerpt from Medicare:
“Counseling and/or Coordination of Care:
Time is only the key or controlling factor in E/M code selection when counseling and/or coordination of care constitute more than 50 percent of the face-to-face or floor time. Documentation in support of these services should include the following:
- Total duration of face-to-face or floor time.
- The duration of counseling or coordination of care and medical-decision making.
- A detailed description of the coordination of care or counseling provided. The documentation needs to provide sufficient information on what was coordinated and what was discussed or advice provided during counseling (You could reasonably insert “to support a medical necessity determination” here). Simple references such as “chart reviewed, RN consulted, reviewed Rx, etc.” is not sufficient.
The physician need not complete a history and physical examination in order to select the level of service. Time spent in counseling/coordination of care and medical decision-making will determine the level of service billed.”
Even with time Medicare is looking at medical decision-making—but not necessarily with their tables. They want to be able to see that the nature of the problems warranted that amount of time.
In more practical terms, if a provider writes that they spent 40 minutes counseling about poison ivy, you can be reasonably certain that this would be down-coded based on medical necessity even with the time. However, if a provider spent 40 minutes addressing coronary artery disease, worsening Stage 4 chronic kidney disease, and end-stage chronic obstructive pulmonary disease, there should be no problem. It just needs to make sense.
Q: I have a physical exam visit that took 40 minutes or longer. Am I better off billing 99215 for time-based coding, or the comprehensive physical exam (CPE) code along with a 99214 for the problem management?
A. It’s not quite as easy as that. You only have the 99215 time-based coding option if you can honestly say that you spent more than half of that time counseling on [insert issues here].
Also, depending on insurance, if this really was a physical with other problem management, patients are entitled to their free health maintenance visit. They would probably need to pay a co-pay on the 99214 portion, however. You may be able to play it either way as above.