Medical necessity and level-IV visits


Fam Pract Manag. 2006 Mar;13(3):26.

Dr. Thomas Waller’s article “Coding Level-IV Visits Without Fear” [February 2006] is one of the best reviews I have seen on this topic. His approach is clear and simple. However, one point deserves emphasis and clarification. Dr. Waller states that the medical decision making component “is often the deciding factor as to whether your visit reaches level-IV status.” I would strengthen this remark to read “is always the deciding factor.”

The reason for this is related to the requirement for the “medical necessity.” I have heard other physicians advocate that a level-IV history and a level-IV physical, without a corresponding level of medical decision making, will satisfy the “two out of three” requirement for an established patient visit. This is simply not so. Some will disagree with me, stating that they are meeting “the letter of the law,” but such a view is not consistent with a fair reading of the entire CPT manual, nor is it consistent with the regulations of Medicare, Medicaid or most other insurers. I do not believe that Dr. Waller is advocating such a misinterpretation of the “two out of three” rule, but some readers might miss this point. We teach our physicians that to reach a level-IV service, one must perform level-IV medical decision making plus a level-IV history or exam. In my experience, 90 percent of the diagnosis is in the history, so I usually opt for that. I congratulate Dr. Waller on his excellent explanation of what is a dismaying and costly topic for many physicians.


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