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The Impact of Medical Necessity on High Level E/M Services

Aimee L. Wilcox, CPMA, CCS-P, CST, MA, MT

I was recently asked the question, "Does 99233 require documentation of a past medical, family, and/or social history (PFSH)?" 

The quick answer is, "it depends."

Code 99233 has the following minimal component requirement:

99233 Component Scoring

Subsequent inpatient E/M encounters can meet the code level requirement either by component scoring & medical necessity or time & medical necessity. Because 99233 is an established patient (EP) E/M code, it only requires scoring in two of the three key components, so as long as medical necessity and any of the following combinations meet the criteria for 99233, it would qualify. 

  • History & Exam (PFSH required)
  • History & MDM  (PFSH required)
  • Exam & MDM    (PFSH NOT required)

So, to answer the original question, "Does 99233 require documentation of a PFSH?" The answer is no, as long as the medical necessity requirement is also met.

Time and medical necessity is the other way to reach 99233. When at least 35 minutes are spent in patient care either at the patient's bedside or hospital floor unit, it too may qualify for 99233, as long as the medical necessity requirement, once again, has also been met. 

What is Meant by Medical Necessity?

The Medicare Official E/M Guidelines (CMS Pub.100-04 Medicare Claims Processing Manual, 30.6.1 "Selection of Level of Evaluation and Management Service") states,

"Medical necessity of a service is the overarching criterion for payment in addition to the individual requirements of a CPT code. It would not be medically necessary or appropriate to bill a higher level of evaluation and management service when a lower level of service is warranted. The volume of documentation should not be the primary influence upon which a specific level of service is billed. Documentation should support the level of service reported."

In other words, the specific components score AND level of medical necessity must be met in order to report E/M code 99233.

Medicare defines medically necessary services as, 

“Healthcare services or supplies needed to prevent, diagnose, or treat an illness, injury, condition, disease, or its symptoms and that meet accepted standards of medicine.”

A good example of not meeting medical necessity would be when a patient presents with an ingrown toenail and no other complicating factors but the podiatrist decides to perform surgery to amputate the entire toe. A bit extreme? Absolutely. A decision to perform major surgery for such a minor problem would not meet accepted standards of medicine nor would it meet medical necessity based on Medicare's definition of medically necessary services. So, how does this correlate with a high level of inpatient service? 

Consider a 25-year-old female patient with no significant past medical history, who presents with upper respiratory symptoms for the past two weeks. She is an established patient but hasn't been seen for more than a year so the provider performs a comprehensive history and examination, which meets the component requirements for 99215. The provider also prescribes an antibiotic and prescription cough syrup to help calm her cough so she can sleep through the night. She is told to return if she isn't feeling better within a few days.

Patient scoring includes a comprehensive history and exam with only moderate medical decision making. Would you report 99215 for this patient simply because the history and exam meet the criteria?

The answer is no. Medical necessity is the overarching criterion in addition to the component scoring and this patient's condition doesn't pose an immediate threat of life or bodily function at this encounter. As a matter of fact, when the documentation is compared to the criteria for a moderate level of risk on the Table of Risk, it matches up perfectly: 

  • Presenting Problem(s): Acute illness with systemic symptoms (upper respiratory infection affecting ENT and respiratory systems)
  • Data Ordered/Reviewed: No testing was ordered or reviewed at this encounter
  • Management Options: Prescription drug management with antibiotic and cough suppressant

This is the perfect example of, "It would not be medically necessary or appropriate to bill a higher level of evaluation and management service when a lower level of service is warranted. The volume of documentation should not be the primary influence upon which a specific level of service is billed."

High Level of Risk

The Table of Risk is a great, yet incomplete, tool that allows an individual to understand medical necessity. This high level of E/M service was required for this patient, during this specific encounter, because their condition is severe, requiring intervention that, in itself, may pose a significant risk to the patient but must be used to save the patient's life or prevent organ system failure or permanent damage. The following is the high level of risk row taken from the Table of Risk, which identifies the level of severity and medical necessity that should be documented in the medical record to support 99233

99233 High Risk

The first column, "Presenting Problems," includes words to describe a patient's condition, illness or injury and uses words like severe, exacerbated, progressing, posing a threat to life or bodily function, and abrupt changes in neurological status. These words accurately describe a patient whose condition is severe and poses an immediate threat.

The second column, "Diagnostic Procedures Ordered," provides examples of some tests, studies, or imaging that in themselves, pose a risk to the patient undergoing them or are of such a nature that they help to clarify the severity of a patient's current condition. Certain cardiovascular studies are, in themselves, risky to perform and wouldn't be ordered unless truly needed to help diagnose a patient's condition or verify a specific course of treatment is needed.

And finally, the third column, "Management Options" lists various treatments that pose a threat to the patient's health alone, even without consideration of the patient's health status while undergoing them. These include major surgery (elective or emergency), which includes a patient who is able to consent or a patient who is in a coma or altered mental state, and must rely on another (sometimes the hospital itself) to decide what is best under the extreme circumstances. There are inherent risks to any patient undergoing major surgery; however, when providers clearly document the risks to this specific patient due to their age, health status, or comorbid conditions, it will better support the higher level of service. Other high-risk conditions include the prescription, dosing, and monitoring of parenteral controlled substances and drugs for toxicity and serious side effects. Some drugs required to keep a patient alive may even need to be monitored or stopped in order to perform emergency surgery, which may put the patient at increased risk yet again. Also, the dreaded decision to de-escalate care, enforce a do not resuscitate (DNR) request, or place a patient into palliative or hospice care demonstrates a high complexity level of service. Additionally, what about those patients who refuse the recommended treatment and by doing so, risk their lives and organ system functions? 

As you can see, a high level of complexity is fairly well defined by the Table of Risk and when reporting 99233, the level of detail within the documentation should likewise support the severity represented by the code and not simply be based on the quantity of documentation in the history or examination components.