DecisionHealth, DecisionHealth - 2012 Issue 2 (February)

Understanding E/M: Determining medical necessity for high-level visits

Question:Our pediatric group tends to do a comprehensive exam and comprehensive history on just about every patient with an acute illness. Acting on CPT guidelines, my staff bills 99215s for these. However, the “overarching” criteria is supposed to be medical necessity.

How can I instruct my staff on what is medically necessary, and what is not? I feel that I can only have them plug the note into the coding formula, and obtain a level of service.

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