Evaluation and Management Services: Finding the Medical Necessity through Documentation Guidelines

By Shannon DeConda, CPC, CPC-I, CPMA, CEMC, CMSCS | July 17, 2014

Earlier this month RACmonitor informed us of the new U.S. Department of Health and Human Services Office of Inspector General (HHS OIG) release encouraging the Centers for Medicare & Medicaid Services (CMS) to place more scrutiny on evaluation and management (E&M) services, with the suggestion based on the staggering statistics surrounding improper payments for these services.

E&M services often are selected incorrectly due to the level assigned being based on documentation content alone. Additionally, electronic health record (EHR) systems that suggest levels of service are utilizing documentation content alone.

Without a clear understanding of medical necessity and the complexity of the patient’s condition as documented within the medical record, the proper level of service cannot be assigned. The big picture that often is missed is that medical necessity goes hand-in-hand with what should be documented as part of the encounter. For example, when we consider CPT code 99212, we envision a patient with a minimal problem.

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