Decision Making for Established Visits

November 19, 2010

While medical necessity is the primary criteria for payment, medical decision making counts too

Question: I have heard that medical decision making should be one of the key components when leveling a subsequent/established patient office visit. I think this is right, but at our institution, we will need something to support this since the documentation rules state two of three key components. Do you have anything in writing to support this?

Answer: Decision making should be one of the key components on established visits. But it isn’t a requirement per se - not in the CPT manual and not in any specific Medicare guidance that I am aware of.

Medicare states that “medical necessity is the over-arching criteria for payment.” The decision-making component - namely how many problems do people have, what is the status of those problems, and what are you going to do about it - is most closely linked to medical necessity which is problem driven.

What you are looking for is not a regulation - it’s just common sense. So, there is no authoritative dictum or guidance that says medical decision making must be one of the two components; it just makes sense that it is. I hope that helps.

Bill Dacey, CPC, MBA, MHA, is principal in the Dacey Group, a consulting firm dedicated to coding, billing, documentation, and compliance concerns. Dacey is a PMCC-certified instructor and has been active in physician training for more than 20 years. He can be reached at billdacey@msn.com or physicianspractice@cmpmedica.com.

This question originally appeared in the February 2010 issue of Physicians Practice.