SHOWING MEDICAL NECESSITY IN E/M CODING
When I use time to report an E/M office visit, must the documentation of my medical decision making (MDM) show medical necessity to support the code selected?
No. MDM is not equivalent to medical necessity. What your documentation must show are the clinical indications for the time you spent and the services you provided to the patient during that time.
For instance, if a physician’s total time documented on the date of a visit is 35 minutes (supporting code 99214) and the diagnosis is influenza-like illness with extended counseling about immunization against common respiratory infections, it is advisable to document the services you provided during the 35 minutes (e.g., history, examination, test orders and results reviewed, management options considered and selected, discussion of the value of influenza immunization despite illness, patient’s questions answered, and patient’s decision regarding immunization). The ICD-10 codes you report should also reflect the visit, e.g., J11.1 and Z71.85 (encounter for immunization safety counseling).
As discussed in the next Q&A, it may be necessary to submit the documentation to support the level of service you reported.
PAYERS REDUCING E/M CODES
Some payers are automatically reducing E/M codes and payment. Is there anything physicians can do about this?
Yes. You can appeal each denial when your documentation supports the code you billed. You may want to provide a cover letter directing the reviewer to the portions of your note that clearly support that the service was reported correctly. Because the first level of appeal may be a cursory or automated review, you may have to appeal to a second level to reach a person who actually considers the merit of your case. Theoretically, winning appeals demonstrates correct coding and may get you removed from the payer’s downcoding program.
Be sure to verify that your diagnosis codes as well as your procedure codes reflect what you addressed during the visit. Payers’ automated downcoding programs may be based partially on presuming that certain diagnosis codes don’t support higher-level E/M codes. You could also consider auditing your code usage and comparing it to local and regional profiles, as some payers say that automatic downcoding is only used for “outlier” physicians.1
SERVICES PROVIDED ON FEDERAL HOLIDAYS
Is it appropriate to report code 99051, “Service(s) provided in the office during regularly scheduled evening, weekend, or holiday office hours, in addition to basic service” for federal holidays when most businesses remain open (e.g., Presidents’ Day)?
While not technically wrong, the intent of the code is that the office is open for regularly scheduled services at times when the average office is not, allowing patients to avoid seeking care at more expensive locations such as emergency departments. The code is meant to cover extra costs of providing this access, not routine business. Payers may vary on this, but if health plans in your area are paying for code 99051, it may be wise to consider limiting its use to evenings, weekends, and major holidays to not give plans a reason to reconsider.
COGNITIVE ASSESSMENT AND CARE PLAN ON SAME DATE AS E/M
Can I separately report code 99483 (cognitive assessment and care plan services) on the same date as an E/M service addressing other chronic conditions?
No. Cognitive assessment and care plan services cannot be reported in addition to E/M services in an office, home, or other residential setting (e.g., assisted living), per the CPT manual. You may separately report an annual wellness visit (G0438-25 or G0439-25) when you provide it on the same date as cognitive assessment and care plan services.
Reference(s)
- 1.Cantrell B. Major insurer resumes downcoding E/M visits for outlier physicians. FPM Getting Paid blog. May 12, 2023. Accessed Nov. 2, 2023. https://www.aafp.org/pubs/fpm/blogs/gettingpaid/entry/elevance-downcoding-resumes.html
