Medical Necessity: Not just LCD Debra L. Patterson, M.D. Medicare Medical Director TrailBlazer Health Enterprises, LLC
Medical Necessity In The Law Social Security Act, Title XVIII Section 1862 (a) (1) (A) "Notwithstanding any other provision of this title, no payment can be made under Part A or Part B for any expenses incurred for items or services which are not reasonable and necessary for the diagnosis or treatment of illness or injury or to improve the functioning of a malformed body member.
Medical Necessity Defined
Medical Necessity vs. Medicare Coverage Benefit Categories and Payment Rules Covered benefits are specified by statute Centers for Medicare and Medicaid Services (CMS) is responsible for implementing Medicare law through promulgating federal regulation Regulation, once placed in interpretive manuals (i.e. MCM, MIM, PIM, others) and/or program transmittals, becomes contractor instruction
Medical Necessity vs. Medicare Coverage Benefit Categories and Payment Rules Inclusion of a service in CPT does not guarantee coverage Inclusion of CPT code in the Medicare Physician Fee Schedule Database does not guarantee coverage
Medical Necessity in Medicare Policy Federal statute National policy (NCD)- developed by CMS Local policy (LCD)- formerly LMRP Developed by Medicare contractors May expand and codify CMS national policy Must not conflict with CMS national policy http://www.cms.hhs.gov/center/coverage.asp
Medical Necessity in Medicare Policy Many (most?) services are paid by Medicare absent of specific written medical necessity policy Absence of national or local policy Vague, non-specific, or non-inclusive existing national and/or local policy
Medical Necessity Defined Determined largely by clinicians and coders based on their experience, knowledge, and judgment Expert consensus opinions Evidence-based literature and clinical practice guidelines Medical textbooks
Medical Necessity in Evaluation and Management Services Medical necessity of E/M services is generally expressed in two ways Frequency of services Intensity of service (CPT level) Documentation must demonstrate that both the frequency and the intensity of the service were appropriate considering the nature of the patient s complaint(s) and condition(s).
Medical Necessity in Evaluation and Management Services At audit, Medicare will deny or downcode E/M services that, in its judgment, exceed the patient s documented needs. It is inappropriate to report to Medicare E/M services at levels higher than are medically necessary regardless of the level at which the service is documented!
Medical Necessity in Evaluation and Management Services CPT Medical Necessity Guidance Contributory factor statement known as Nature Of Presenting Problems contained in most CPT E/M code descriptions. CPT Appendix C - Clinical Examples.
Medical Necessity The number of problems for which physician work of evaluation and management is clearly demonstrated Key component work Appropriate for and addresses the problem/complaint Supports conclusions Supports evaluations and treatments chosen Counseling and coordination Well documented Appropriate for the problem
Medical Necessity Acuity and/or duration of the problems evaluated and managed; the context among all other services previously rendered for the problems Acute Sub-acute Chronic
Medical Necessity Acuity and/or duration of the problems evaluated and managed; the context among all other services previously rendered for the problems Sub-acute problem Potential for worsening, recurrence or negative consequences Acute problem, now resolved, but outcome was still questionable when last seen
Medical Necessity Acuity and/or duration of the problems evaluated and managed; the context among all other services previously rendered for the problems Chronic problem Well controlled or inactive Periodic monitoring well established as standard of medical practice Potential for loss of control based on individual s history Poorly controlled, decompensated, or exacerbated
Medical Necessity Severity of problems (risk for morbidity and/or mortality) evaluated and managed Minor or self-limited Low severity Moderate severity High severity
Medical Necessity in Evaluation and Management Services self-limited or minor A problem that runs a definite and prescribed course, is transient in nature, and is not likely to permanently alter health status or has a good prognosis with management/compliance low severity A problem where the risk of morbidity without treatment is low; there is little to no risk of mortality without treatment; full recovery without functional impairment is expected
Medical Necessity in Evaluation and Management Services moderate severity A problem where the risk of morbidity without treatment is moderate; risk of mortality without treatment; uncertain prognosis OR increased probability of prolonged functional impairment high severity A problem where the risk of morbidity without treatment is extreme; there is moderate to high risk of mortality without treatment OR high probability of severe, prolonged functional impairment
Medical Necessity Severity of problems (risk for morbidity and/or mortality) evaluated and managed Elective visit occurred at patient and/or physician s convenience Semi-urgent visit required and occurred within several days of onset Urgent visit required and occurred within a day of onset Emergent visit required and occurred within hours of onset
Medical Necessity Physical scope encompassed by the problems (number of physical systems actually affected by or related to the problems) evaluated and managed 1-3 systems 4-6 systems 7-9 systems 10 or more systems
Medical Necessity Complexity of co-morbidities that have been documented to have clearly influenced physician work Complicate the presenting problem(s) Not separately counted as problems
Medical Necessity: Not just LCD Terry Reeves Institutional Compliance Officer Office of Institutional Compliance HCCA April 2006
The 7 Components of an E/M History Physical Examination Medical Decision Making Counseling Coordination of Care Time Nature of the presenting problem
Nature of the Presenting Problem 99212 Usually the presenting problems are self-limited limited or minor 99213 Usually the presenting problems are of low to moderate severity 99214 Usually the presenting problems are of moderate to high severity 99215 Usually the presenting problems are of moderate to high severity
How do these look? 99212 99213 99214 99215
What is the difference between Chief Complaint and Nature of the Presenting Problem? Patient presents with a Chief Complaint of sore throat. cc: problem focused After history and exam and lab- the patient has strep throat. Now, what level is the Nature of the Presenting Problem? pp: low to moderate
Does the level change? Now, what if this patient was 18 months old (and documented)? CC: problem focused PP: moderate to high severity Now, what if this patient has unstable diabetes? (documented) CC: problem focused PP: moderate to high severity
Does the level change? Now, the patient has stable hypertension which the physician does not address in the documentation of this visit. CC: sore throat PP: strep Does the patient s s history add to the complexity if it is not addressed during this encounter?
What adds to the Nature of the Presenting Problem? The complexity of co-morbidities that have been documented to have clearly influenced the physician work (for this encounter) can add to the complexity because they complicate the presenting problem(s). If the co-morbidities are listed but not documented to effect this encounter, they do not add to the complexity for this level of service.
What is the correct level? An established patient presents with recurrent tennis elbow after discontinuing NSAID. The physician takes a problem focused history, examines the elbow, and recommends a different OTC medication. The correct CPT code would be
What is the correct level? The correct answer is 99212 because there was a problem focused history, a problem focused exam (only the elbow), a straight forward medical decision making, and the presenting problem was self-limiting limiting or minor.
Add to the complexity Patient described that they discontinued the NSAID due to GI upset Physician had also examined the abdomen Ordered an Upper GI Documented an expanded history and physical The correct code would then be
The correct answer is 99213 because this is now an expanded problem focused history; an expanded problem focused exam was done, medical decision making increased, and the presenting problem is now more a low to moderate severity.
What is this level? An established patient presents for a periodic follow up visit. The patient has chronic asthma and type 2 diabetes, both are stable on current meds. The physician takes a history regarding both problems (expanded problem focused), examines the patient, and continues the current meds (medical decision making of low complexity). The correct code would be
The correct answer is 99213 because there was an expanded problem focused history, expanded problem focused exam, medical decision making of low complexity, and presenting problems are low to moderate severity.
In this same service, if the physician documented a comprehensive history and examination, could they bill a 99215 for this visit? No, the volume/level of detail of the documentation is not the determining factor for Level of Service.
Now how about this one? Mr. Locke is a 70 year old white male who complains of moderate, persistent pain in his left arm for the past five days. The pain radiates from the shoulder toward the elbow and wrist. Each episode lasts about ten minutes. He has some shortness of breath. Patient states he fell from a ladder six days ago.
Coding with an Electronic Medical Record What information is actually reviewed for this Date of Service (DOS)? What information is blown in from the prior visits/patient history? What information is part of a pre-formatted template? Is the information all medically necessary for this DOS??????
Example Date of Visit 12/20/05 3 year old male here today with the following complaints: cough, nasal congestion, post-nasal drip, rhinorrhea, yellow and fever present last week, treated by outside doctor (?ER) started on Augmentin and now having diarrhea and really bad diaper rash. Has pus draining from left ear. Also with: fever:improving, but still present eye problems: none ear problems: complaints of tugging from left ear throat problems:none abdominal pain: none vomiting: none diarrhea: yes since starting abx, no blood hydration concerns: slightly decreased po intake; normal urinary output activity level: mildly decreased sick contacts: none Date of Visit 1/20/06 3 year old male here today with the following complaints: cough, nasal congestion,post-nasal drip present for 3 day(s) occurring primarily at any time. Also with: fever: improving, but still present eye problems: none ear problems: complaints of tugging from left ear throat problems:none abdominal pain: none vomiting: none diarrhea: none hydration concerns: slightly decreased po intake; normal urinary output recent illnesses: h/o ear infections with tubes in place activity level: normal sick contacts: attends daycare
Example Date of Visit 12/20/05 PHYSICAL EXAM Temp (Src) 98.3 (Tympanic) Wt (32 lbs) General: uncooperative, uncomfortable Eyes: pupils equal, round, reactive to light and conjunctiva clear Ears: R TM: PE tube(s) present, patent and dry, L TM: PE tube(s) present with purulent drainage Nose: purulent discharge Throat: moist mucous membranes, normal tonsils without erythema, exudates or petechiae Neck: supple and no lymphadenopathy Lungs: Positive for expiratory wheezes: bilaterally, diffusely Heart: regular rate and rhythm, no murmur Abdomen: normal bowel sounds, soft, non- tender, non-distended, no hepatosplenomegaly or masses Skin: pink, warm,, diaper rash has little red bumps all around area, no ecchymosis Rapid Strep Result: not needed today Date of Visit 1/20/06 PHYSICAL EXAM Temp (Src) 98.4 (Tympanic) (32 lbs) General: alert, active, in no acute distress Eyes: pupils equal, round, reactive to light and conjunctiva clear Ears: R TM: PE tube(s) present, patent and dry, L TM: PE tube(s) present,, patent and a couple of drops of fluid coming from tube Nose: clear discharge Throat: clear post-nasal drainage present Neck: supple and no lymphadenopathy Lungs: clear to auscultation Heart: regular rate and rhythm, no murmur Abdomen: normal bowel sounds, soft, non-tender, non-distended, no hepatosplenomegaly or masses Skin: pink, warm,, no rashes, no ecchymosis Rapid Strep Result: not needed today
Example Date of Visit 12/20/05 ASSESSMENT Tube Otitis Candidal Rash Diarrhea PLAN Plenty of rest and increase liquids. Acetaminophen, ibuprofen as directed. floxin bid 5-77 days to left ear nystatin cream apply qid prn Omnicef bid 5 days Date of Visit 1/20/06 ASSESSMENT Tube otitis Uri PLAN Plenty of rest and increase liquids. Acetaminophen, ibuprofen as directed. floxin bid z-cof dm
The documentation should not contradict the level of service! patient was eating a sandwich and complaining about the TV channel selection with critical care ER visit child was happy and playing comfortably with a high level E/M visit
Questions?