Medical Necessity in E/M Coding, Part 3: Correctly Coding the Physical Exam

DAVID STERN, MD (Practice Velocity) Some coding auditors do not understand the urgent care setting. As a result, they have been inappropriately downcoding evaluation and management (E/M) levels— not based on levels of documentation, but rather on whether the documentation is supported by their “view” of medical necessity, even though these auditors have usually never been providers and lack clinical experience. In this situation, the best defense is a strong offense. This column reviews medical …

Read More

Medical Necessity in E/M Coding, Part 2: ROS and PFSH

DAVID STERN, MD (Practice Velocity) Last month, we presented definitions for medical necessity offered by the AMA and the Centers for Medicare & Medicaid Services (CMS). We looked at the elements appropriate to perform and document in the History of Present Illness (HPI). And we briefly discussed Recovery Audit Contractors (RAC) audits. (If you missed it, the column is archived on the JUCM website [https://jucm.com] in the May 2011 issue.) This month, our focus is …

Read More

Medical Necessity in E/M Coding

DAVID STERN, MD (Practice Velocity) Q.Recently some of my charts were audited and the payor challenged the levels of the evaluation and management (E/M) codes I had used. The payor said that the charts were actually coded correctly, based on the information that was documented on the chart. The auditor, however, challenged what she called the “medical necessity” of the documentation. She claimed that, based on the patients’ chief complaints, many elements of the E/M …

Read More