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How to code varies on the circumstances. Many coding scenarios are determined by context-not absolutes.
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:
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.