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Spelling Out Medical Necessity; Duplicative Coding


Answers from our coding expert on questions regarding medical necessity; using the ROS for history of presenting illness; and duplicative coding.


Q:  Does a diagnosis code alone support medical necessity for lab tests?  Shouldn’t there be something in the note documenting a sign/symptom or current status of the condition?  I do not think that by simple virtue of having a confirmed diagnosis that lab tests are always medically necessary.

A:  Medical necessity is largely determined by the payer community, usually assigned to them by your contract. There are a few ways to look at this.

From a purely payer policy perspective many lab codes have pre-determined lists of payable diagnoses codes, some with lists of necessary but non-payable codes and some with lists of always non-payable codes. This is by payer policy alone and not dependent on documentation.

If you are asking what documentation needs to be in the chart to support a given diagnosis, this is a slightly different question. The ICD-10-CM Official Guidelines for Coding and Reporting give the following two sets of guidance:

"For encounters for routine laboratory/radiology testing in the absence of any signs, symptoms, or associated diagnosis, assign Z01.89, Encounter for other specified special examinations. If routine testing is performed during the same encounter as a test to evaluate a sign, symptom, or diagnosis, it is appropriate to assign both the Z code and the code describing the reason for the non-routine test.

For outpatient encounters for diagnostic tests that have been interpreted by a physician, and the final report is available at the time of coding, code any confirmed or definitive diagnosis documented in the interpretation. Do not code related signs and symptoms as additional diagnoses."

In all of the cases described above, absence of signs/symptoms or tests to evaluate a sign or symptom, we would expect that the earlier part of the note, the history of presenting illness (HPI), would develop the reason for the encounter and any problems or contexts that would necessitate diagnostic testing.

The third "General Principle of Medical Record Documentation" from the Federal Documentation Guidelines is:

"If not documented, the rationale for ordering diagnostic and other ancillary services should be easily inferred."

So between the ICD-10 Guidelines and the Federal Documentation Guidelines, it is pretty clear the reason for every test needs to be spelled out. Whether a payer recognizes necessity is a different story.


Q: I have a provider whose every note begins, "Patient … is seen for initial visit. See review of systems (ROS) for wording." The intent from the provider is that the ROS contains the history of presenting illness.

A: Show the provider the definition of an HPI from the Federal Guidelines:

"The HPI is a chronological description of the development of the patient's present illness from the first sign and/or symptom or from the previous encounter to the present. It includes the following elements:

• Location,

• Quality,

• Severity,

• Duration,

• Timing,

• Context,

• Modifying factors, and

• Associated signs and symptoms."

Unless the ROS contains these types of descriptors and they usually don’t, for new patients I doubt the HPI will ever get past a 99202.


Q:Some providers in our network are billing a 99397, a G0439 and a 99214 plus various labs all on the same day. Isn’t this duplicative? It is very expensive for the patients.

A: Technically there is no reason that all of these codes cannot be billed on the same day if they are performed, properly documented, and meet coverage criteria.

That said there are other considerations as you point out. First of all, it is a given that it is a Medicare eligible patient as a 99397 means the patient is 65 or older and the G0439 is a Medicare follow-up Annual Wellness visit. The 99397 is also a Medicare non-covered service so that in no circumstances is it payable by Medicare - so you have one of those considerations you mention above.

It is a very common scenario to see a G0439 and a 99214 billed together. This is typically the fourth of four visits in a year, or perhaps some in lesser intervals, where the patient’s chronic issues are addressed (99214) and the provider also does the annual wellness check (G0439). We expect to see these combinations in large numbers and Medicare recognizes the long-term saving and health benefits of these interventions.

Of note, the G0439 does not include a comprehensive physical exam or any exam beyond vitals; it is geared more toward history and prevention assessments and plans.

This is what leaves a bit of a vacuum where some providers feel a 99397 is appropriate. That code calls for an age and gender appropriate history; exam and risk factor reduction intervention; and counseling/anticipatory guidance.

The detailed descriptions of the AWV codes G0438/G0439 does cover the history, risk factor, and guidance functions pretty well. It also includes a complete schedule for 10 years worth of upcoming screening tests. The notable exception is the exam.

One view is it is somewhat assertive to bill the 99397 when close to 75 percent of the code description is covered by another code in the same encounter.

However, other providers feel very strongly that the comprehensive exam, beyond anything done with the problem portion of the visit, is a critical piece of patient preventive maintenance that Medicare left out of the AWV codes. They counsel their patients to pay out of pocket for this portion of the encounter.

Medicare has not directly addressed this combination of codes, but has said that their Initial Preventive Physical Examination (IPPE) visit (G0402) probably has too much overlap to bill together. That code does include an exam.

"Non-covered preventive services, including Evaluation and Management (E&M) services, may be furnished with an Initial Preventive Physical Examination (IPPE) visit. However, we would hope that the provider would notify the patient that the additional services are non-covered by Medicare and that the payment for the additional non-covered preventive services will fall to the beneficiary. We further note that non-covered E&M preventive services will have substantial overlap with the service elements furnished in the IPPE visit and that practitioners are responsible for billing appropriately when providing additional non-covered E&M preventive services in conjunction with an IPPE."

Most recently some Medicare managed care organizations have actually encouraged their providers to use this code combination to help them "make their numbers." A payer asking a provider to essentially code higher or more is unusual, but in this changing healthcare marketplace there are many interests to serve.

At the end of the day, there is nothing improper about that coding combination. But make sure that the provider is quite clear on their rationale for every component of it, and that the patient is aware of the health and insurance benefits for each component.

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