Let's Talk High Risk E/M Services
By Aimee Wilcox, CPMA, CCS-P, CMHP, CST, MA, MT
March 21, 2019
Have you ever assigned a high-complexity E/M code (e.g., 99205, 99215, 99223, 99233, 99245, etc.) and wondered if it would stand up to further scrutiny? Well, let’s take a closer look at the requirements for reporting high-level E/M services.
Both the American Medical Association and Medicare-published E/M Guidelines agree that a high level of complexity and medical necessity must be supported in the medical record to report a high-level E/M service. This may be accomplished in one of two ways:
Component scoring requirements for a new patient (NP) differs from those of an established patient (EP), in that NPs require criteria from all three key components to be met while only two of the three must be met for an EP. Both, however, require the same high-level medical necessity.
Component requirements include:
Find-A-Code subscribers can see the details of what is required in component scoring by using our E/M Calculator. Nonsubscribers can also use the E/M Calculator by signing up for a free trial, which will allow you to use the many fabulous tools available to you for 28 days, without any additional obligation to purchase.
Determining the highest level of E/M based on time depends on the E/M category the service falls into and medical necessity.
Determining the E/M level based on time requires the provider document the total face-to-face time spent counseling and coordinating care with the patient, a summary of what was counseled and coordinated, and specifying that more than 50% of the total face-to-face time spent with the provider was actually used for counseling and coordinating this care.
Some examples of what might be considered high-complexity could include (but are not limited to):
As you can see by the information provided, when considering assignation of a high-complexity E/M service, the documentation really needs to paint a picture of a patient who is in a serious situation with their health due to acutely severe or chronically exacerbated conditions.
The other half of MDM and Time is identifying whether or not the documentation supports medical necessity. It may seem as if medical necessity is difficult to assess, and in some cases, it may very well be; however, once again, the Table of Risk helps to clarify what patient conditions or circumstances not only warrant a high level of E/M service but also support it. Providers can always improve their documentation, especially when it comes to reporting high-level E/M services, by including the specific risks to the patient (not all patients, but the particular patient for whom they are making medical decisions). Also, including any complicating factors, like comorbidities currently exacerbating the problem or complicating decision making for this encounter, why urgent or complex treatment is required, and of course, if surgery is needed promptly, why and the risk to the patient by undergoing surgery or opting to postpone it help to establish medical necessity.
Documenting the details allow reviewers to quickly identify medical necessity for the decision making taking place and the high-level E/M service being reported.
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