Special Report: Integrating NPP into E/M

While the CMS documents provide details of the three “key components” of the E/M system,
thorough understanding of compliant E/M documentation and coding must necessarily include
consideration of the Nature of the Presenting Problem(s) (“NPP”), an additional E/M component that
the AMA publication “Current Procedural Terminology” (CPT®) identifies as one of three
“contributory factors.”¹ This is because “the NPP is the CPT coding system’s E/M vehicle for
evaluating medical necessity,”² and as explained by the Centers for Medicare and Medicaid Services
(“CMS”), “Medical Necessity of a service is the overarching criterion for payment in addition to the
individual requirements of a CPT code.”³ This principle derives from Social Security Law, which
mandates “Medicare will not pay for services that are not medically necessary.”⁴ Therefore,
submission of a high level of E/M service is not warranted if the presenting problem has relatively low
severity of NPP (e.g., a sprained ankle, a viral upper respiratory infection, or an uncomplicated urinary
tract infection), even if there has been extensive documentation of medical history, physical
examination, and medical decision making (the three key components). This is because the NPP fails
to support the medical necessity of these high levels of care.

The following excerpts quoted from the American Medical Association’s own publication
about E/M compliance clarify the concept of the nature of the presenting problem and explain how
physicians should incorporate this concept into both patient care workflow and compliant
documentation and coding.

More Items in June 2011

• Jun 28, 2011
  Dorland's Updates
• Jun 27, 2011
  Scrub-A-Claim™ enhancements
• Jun 14, 2011
  New Product: DecisionHealth Article Database
• Jun 06, 2011
  April 2011 CPT® Assistant Available
• Jun 04, 2011
  Scrub-A-Claim™ is now available!
• Jun 01, 2011
  New This Month (June 2011)

To view more items select a month from our "Items by Month" list.

Or view documentation, coding and billing articles.