tci Medicare Compliance & Reimbursement - 2012 Issue 24
Reader Question: Medical Decision Making Is Not The Same As Medical Necessity
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Article Overview
This reader question addresses evaluation and management (E/M) coding guidance focused on selecting the appropriate overall level of service. It explains the role of medical necessity, highlights concerns related to automatically coded encounters in EHR systems, and discusses the difference between medical decision making and medical necessity. The article is intended for coders, billers, auditors, and clinical documentation staff who review E/M services and documentation practices.
Why This Topic Matters
Understanding the distinction between documentation elements and medical necessity helps reduce inappropriate E/M level selection and supports more accurate coding review.
What You Will Learn
- How medical necessity relates to E/M level selection
- Why documentation completeness alone may not support a higher service level
- How automated EHR coding can affect encounter leveling
- Why medical decision making should not be treated as identical to medical necessity
Who Should Read This
- Medical coders
- Coding auditors
- Billers
- Physician documentation staff
- Practice managers
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