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American Academy of Family Physicians
Tuesday Jun 17, 2014

Potential pitfall in Medicare billing: office visits billed for hospital inpatients

This week, we conclude our series (see previous posts here, here, and here) on how to avoid common Medicare billing errors by focusing on billing the wrong kind of evaluation and management (E/M) code for patient visits provided in a hospital inpatient setting.

If you are rendering an E/M service to a patient in an inpatient hospital setting, then you should typically report that service with a CPT code from one of the following families:

•    99221-99223 – Initial hospital care
•    99231-99233 – Subsequent hospital care
•    99238-99239 – Hospital discharge services

Unfortunately, Medicare contractors are finding that physicians sometimes use a CPT code from the 99201-99215 family (Office or other outpatient services) for encounters with hospital inpatients. The example given is an 80-year-old female admitted to a hospital for an inpatient level of care on Oct. 17 and discharged on Oct. 20. A physician billed CPT code 99205 (Office or other outpatient visit for the evaluation and management of a new patient) for the date of service of Oct. 18. Because Oct. 18 was during the inpatient hospital stay and the patient was not on a leave-of-absence from the hospital on that date, the contractor deemed the service an overpayment.

So, if you are billing E/M services for a patient in an inpatient hospital setting, then you need to use hospital visit codes to report those services and avoid office/outpatient visit codes for dates of service corresponding to the patient’s hospital stay.

For additional information, check out Medicare’s Evaluation and Management Services Guide and sections 30.6.9.1, 30.6.9.2, and 30.6.10 of chapter 12 of the Medicare Claims Processing Manual.

– Kent Moore, Senior Strategist for Physician Payment for the American Academy of Family Physicians

Friday May 30, 2014

Potential pitfall in Medicare billing: psychotherapy in conjunction with an evaluation and management service

Four times a year, the Centers for Medicare & Medicaid Services (CMS) publishes its Medicare Quarterly Provider Compliance Newsletter, which seeks to help physicians avoid common Medicare billing errors. The latest issue highlights at least four errors that may be relevant to family physicians. This week, we’ll cover one related to psychotherapy provided in conjunction with an evaluation and management (E/M) service.

Family physicians are often the first point of contact for patients with mental health issues and sometimes provide psychotherapy to such patients in addition to an E/M service at the same encounter. Since January 2013, these services provided by the same provider on the same day are separately reportable and payable as long as they are significant, separately identifiable, and billed using the correct codes. In this situation, designated add-on codes are used to report psychotherapeutic services performed in addition to E/M codes.

Those CPT codes are:

•    +90833: Psychotherapy, 30 minutes with patient and/ or family member when performed with an E/M service
•    +90836: Psychotherapy, 45 minutes with patient and/ or family member when performed with an E/M service
•    +90838: Psychotherapy, 60 minutes with patient and/or family member when performed with an E/M service

CPT provides flexibility by identifying time ranges that may be associated with each of the timed codes:

•    90833: 16 to 37 minutes
•    90836: 38 to 52 minutes
•    90838: 53 minutes or longer

Psychotherapy sessions lasting less than 16 minutes are not separately reportable.

Documentation is crucial here. Time spent for the E/M service must be recorded separately from the time spent providing psychotherapy, and time spent providing psychotherapy cannot be used to meet criteria for the E/M service. Physicians can't enter one time period that includes both the E/M service and the psychotherapy.

CMS identified this blending of time periods as a common billing error in its quarterly newsletter. For example, a physician billed for a level 3 E/M service (99213) and 45 minutes of psychotherapy (90836). However, an authenticated printed visit note from the physician's electronic health record indicated total face-to-face time with the patient of 45 minutes and did not separately indicate the time spent providing psychotherapy services. The Medicare contractor, after an unsuccessful request for additional information, counted the claim as an overpayment due to insufficient documentation and recouped the payment from the physician.

Next week:  pitfalls associated with preventive services

– Kent Moore, Senior Strategist for Physician Payment for the American Academy of Family Physicians

Tuesday Feb 18, 2014

HHS inspectors to review Medicare coding problems in 2014

It's a few months later than normal, but the U.S. Department of Health and Human Services (HHS) Office of Inspector General (OIG) has finally released the list of areas its auditors will target this year.

The OIG usually releases the document in the fall. However, the agency delayed its release until now to better align with priorities that the HHS has set for the year.

Some of the items in the 2014 Work Plan will be of interest to family physicians.

First, OIG will look into reports from Medicare contractors who say they've seen an increase in providers filing medical claims for different evaluation and management (E/M) services but using identical documentation. Medicare requires providers to select the billing code for a service on the basis of the unique content of the particular service and have documentation to support the level of service reported. The agency said it plans to review multiple E/M services associated with the same providers and beneficiaries to determine the extent of documentation vulnerabilities – and potentially inappropriate payments.

The OIG will also review the extent to which physicians and suppliers participated in Medicare and accepted claim assignment during 2012. As part of that review, OIG will assess the effects of participation and claim assignments on the Medicare program, such as noncompliance with assignment rules, and on beneficiaries, such as excessive billing of beneficiaries’ share of charges.

Third, OIG will review physicians’ coding on Medicare Part B claims to make sure they provided the proper place of service codes for services performed in ambulatory surgical centers and hospital outpatient departments. Prior OIG reviews have found a problem with incorrect coding of place of service on Part B claims. Mis-coding can have a big effect on program payments because Medicare pays a physician more when a service is performed in a non-facility setting, such as a physician’s office, than it does for services performed in a hospital outpatient department or, with certain exceptions, an ambulatory surgical center.

For a full list of issues, including others that may be relevant to your particular practice, consult the complete OIG 2014 work plan online.

– Kent Moore, Senior Strategist for Physician Payment for the American Academy of Family Physicians

Friday Nov 08, 2013

Billing E/M services with allergy procedures is getting Medicare's attention

If you routinely bill evaluation and management (E/M) services with allergy testing or allergy immunotherapy, expect to receive increased scrutiny from Medicare in the future.

The latest issue of the Medicare Quarterly Provider Compliance Newsletter highlights that recovery auditors have identified this type of coding combination as a potential problem, resulting in what auditors determined were overpayments.

According to the Medicare Claims Processing Manual (Chapter 12, Section 200, subsection C), to receive payment for a visit service provided on the same day that you also provide an allergen immunotherapy service (i.e., any service in the series from 95115 through 95199), you must bill a modifier 25 with the visit code. This indicates that the patient’s condition required a significant, separately identifiable visit service above and beyond the allergen immunotherapy service you provided. The newsletter also notes that obtaining informed consent is included in the immunotherapy service and should not be reported with an E/M code.

Medicare assumes that allergy injections are typically pre-scheduled and that no other services beyond the injection are usually scheduled at the same encounter. Also, Medicare doesn't believe an E/M code is needed to report the minimal amount of work used to determine if the patient is fit to undergo an allergy injection, believing the injection code already includes that work. However, Medicare recognizes that things don’t always go according to schedule, and you may properly bill for these significant, separately identifiable services using modifier 25 for claims processing.

To see if you're potentially running afoul of these rules, Medicare recommends that physicians pull the documentation for a sample of past instances where they billed Medicare for E/M services tied to scheduled services and compare the “visit intent” against the content of the notes.

– Kent Moore, Senior Strategist for Physician Payment for the American Academy of Family Physicians

Thursday Aug 29, 2013

Latest CCI edits make it tougher to report E/M service with minor procedures

New changes to Medicare coding rules will make it tougher to report evaluation and management (E/M) services provided on the same date as many minor procedures.

The latest version of the Correct Coding Initiative (CCI) edits, designated CCI 19.2 and effective July 1, 2013, bundle E/M services with many common outpatient procedures, including, but not limited to:

•    Skin procedures, such as simple (12001-12021) and intermediate (12031-12057) repair of a laceration and destruction of benign and premalignant skin lesions (17000-17250);
•    Musculoskeletal procedures, such as therapeutic injections of tendons and trigger points (20526-20553), aspiration and/or injection of a joint (20600-20610), and application of casts and strapping (29000-29750);
•    External ear procedures, such as foreign body removal (69200) and impacted cerumen removal (69210).

Affected E/M codes include:

•    Established patient office/outpatient visits (99211-99215)
•    Hospital inpatient visits (99221-99239)
•    Consultation codes (99241-92255)
•    Critical care codes (99291-99292)
•    Nursing facility codes (99304-99316)
•    Established patient domiciliary, rest home, or custodial (assisted living) care codes (993234-99337)
•    Home visits with established patients (99347-99350)
•    Care plan oversight (99374-99378)

The new edits mean that if you report both services for the same patient on the same date without an appropriate modifier appended to the E/M code, Medicare (and any other payer that uses the CCI edits) will only pay for the procedure code.

The CPT surgical package definition says that surgical procedure codes include, subsequent to the decision for surgery, one related E/M encounter on the date immediately prior to or on the date of the procedure. That means these procedures, by definition, include a certain amount of “evaluation and management” in them, and the CCI edits reinforce that presumption.

Thankfully, the modifier indicator for all of these edits is "1." That means you can override the edits with the proper modifier. In this case, the most appropriate modifier will typically be modifier 25 (Significant, separately identifiable evaluation and management service by the same physician or other qualified health care professional on the same day of the procedure or other service).

All of this means that any time you do an E/M service and a procedure on the same date of service, you should consider whether or not there is an applicable CCI edit. If there is, your documentation should support that the E/M service was significant and separately identifiable before you report it, and if so, you should add modifier 25 to the E/M code to make sure it gets paid.

– Kent Moore, Senior Strategist for Physician Payment for the American Academy of Family Physicians

Tuesday Jul 16, 2013

UnitedHealthcare jumping on vaccination bundling bandwagon

One of the nation's largest insurers is piggybacking on new restrictions that complicate physicians getting paid for performing vaccinations.

UnitedHealthcare (UHC) announced in its July 2013 Network Bulletin that it will align with Correct Coding Initiative (CCI) edits that went into effect Jan. 1, 2013. These changes, detailed in a February blog, affect evaluation and management (E/M) services and immunization administration codes.

UHC said that beginning in the third quarter of 2013 it will deny Current Procedural Terminology (CPT) codes 99201-99380 and 99401-99499 when reported on the same date of service as an immunization administration service (CPT codes 90460-90461 and 90471-90474). However, if the E/M code is reported with modifier 25, indicating it is a significant and separately identifiable service provided on the same day, UHC will pay for both codes. On the plus side, this policy change will not apply to preventive medicine E/M services (CPT codes 99381-99397 and Healthcare Common Procedure Coding System code G0402), which is often the type of E/M service during which vaccines are administered. 

No word yet on what other payers may also be following suit, but it’s a safe bet that UHC is not alone and will not be the last.

– Kent Moore, Senior Strategist for Physician Payment for the American Academy of Family Physicians
 


Thursday May 30, 2013

Split/shared evaluation and management services get attention

The Centers for Medicare & Medicaid Services (CMS) is issuing a friendly reminder to be careful when coding patient visits that involved services from both a physician and a non-physician provider.

In the latest Medicare Quarterly Provider Compliance Newsletter, a publication designed to help avoid common billing errors and other erroneous activities when dealing with Medicare, CMS focused on split/shared evaluation and management (E/M) services.

As CMS notes, a split/shared E/M services is an encounter in which a physician and a non-physician provider (NPP), such as a nurse practitioner or physician assistant, each personally performs a substantive portion of an E/M visit face-to-face with the same patient on the same date of service. This is not uncommon in family medicine.

Unfortunately, CMS and its auditors have identified such visits as a source of common billing errors, most often because of insufficient documentation errors. More specifically, there was insufficient documentation to support that both the physician and NPP performed a substantive portion of the split/shared E/M service. CMS offers the following example:

A split/shared E&M claim was submitted for payment. While the submitted documentation contained a physician's signature on the NPP's clinical note, no other documentation was made by the physician supporting that the physician performed a substantive portion of the split/shared E&M service. This claim was scored an improper payment due to an "insufficient documentation error."

Proper documentation of split/shared E/M services plays into whether the service is billed under the physician's national provider identifier (NPI) or that of the NPP. That, in turn, affects the level of payment, since Medicare typically pays services billed under an NPP's NPI at a rate less than what it pays a physician for the same service.

For more information beyond the newsletter, CMS encourages you to look at Chapter 12, Section 30.6, of the Medicare Claims Processing Manual and Chapter 15, Section 60, of the Medicare Benefit Policy Manual. You can also view the Evaluation and Management Services Guide on the CMS website.

– Kent Moore, Senior Strategist for Physician Payment for the American Academy of Family Physicians

Thursday Feb 14, 2013

CMS providing some help on vaccine-related E/M coding change

The Centers for Medicare & Medicaid Services (CMS) is providing some limited relief to physicians dealing with recent changes to how they're paid for vaccinations.

As this blog covered previously, the Jan. 1 round of Correct Coding Initiative (CCI) edits required that providers append modifier 25 to evaluation and management (E/M) services performed in connection with immunization administration services (90460-90474) provided on the same date to the same patient or only get paid for the immunization administration.

Subsequent to that post, I learned that CMS sent an alert on Feb. 1 to all state Medicaid agencies. The alert allows each state to deactivate the edits as they pertain to preventive medicine service codes (99381-99397) and immunization administration codes, retroactive to Jan. 1.

The deactivation is only applicable for the first quarter (Jan. 1-March 31, 2013). It's also up to each individual state Medicaid agency, and each state that does deactivate the applicable edits will have to individually decide whether to reprocess Medicaid claims already submitted since the beginning of the year.

CMS said it expects that state Medicaid agencies that choose to retain the edits will educate physicians on the proper E/M coding and use of modifier 25 to bypass the edits.

CMS has not made any unilateral decisions to deactivate these CCI edits nationally at this time, so outside of Medicaid in those states that choose to deactivate them, the new edits remain a hassle.

Still, some relief is better than none, and the American Academy of Family Physicians and other medical societies are continuing to ask CMS to rescind the edits at all levels.

– Kent Moore, Senior Strategist for Physician Payment for the American Academy of Family Physicians

Thursday Feb 07, 2013

Pay attention, or don't get paid for E/M services performed with vaccinations (UPDATED)

Getting fully reimbursed for vaccinations is now requiring a little extra effort.

The latest round of edits for the Correct Coding Initiative (CCI) went into effect Jan. 1 and included around 300 changes that affect evaluation and management (E/M) services and immunization administration, specifically codes between 90460 and 90474.

In each edit, the administration code trumps the E/M code. That means if you bill a vaccine administration code and an E/M code for the same patient on the same date and do not append a modifier to the E/M code, Medicare and other payers who follow the CCI edits will only pay for the vaccine administration.

The idea behind the edits is that an E/M service provided at the same encounter as a vaccine administration should be a significant and separately identifiable service. Vaccine administration by itself does not merit both the administration code and an E/M code.

If, however, the situation merits separate reporting and you have supporting documentation, you can attach a modifier (such as modifier 25) to the E/M code and report both services. The one exception is E/M code 99211 (office or other outpatient visit for the evaluation and management of an established patient that may not require the presence of a physician). CCI will not allow the addition of a modifier to report both 99211 and a vaccine administration. That edit is not new.

Both the American Academy of Family Physicians and American Academy of Pediatrics are protesting the new edits, saying they needlessly complicate physician billing practices and don't appear necessary under current CPT language.

They also worry that placing additional barriers to practices seeking proper payment for immunizations will lead to fewer people getting vaccinated. That's obviously a problem for both public and individual health and comes at a time when the Centers for Disease Control and Prevention has lamented the unacceptably low adult immunization rates in the United States.

Considering that the CCI is overseen by the Centers for Medicare & Medicaid Services, it appears once again that Uncle Sam’s right and left hands don’t know what each other are doing or that, even if they do, the consequences are just as disastrous.

2/14/13 UPDATE: CMS gives state Medicaid programs some leeway in following new vaccination E/M coding changes.

– Kent Moore, Senior Strategist for Physician Payment for the American Academy of Family Physicians

Tuesday Sep 18, 2012

Putting E/M services on the RAC

In July, I posted about a report from the U.S. Department of Health & Human Services Office of the Inspector General (OIG) which found that from 2001 to 2010, physicians increased their billing of higher level evaluation and management (E/M) codes in all types of E/M services. In that post, I encouraged you to make sure that your documentation supports the level of E/M services that you are billing. With the OIG paying attention, the Centers for Medicare & Medicaid Services (CMS) were likely to follow suit, and you needed to be prepared.

Well, it appears that CMS was paying attention, or at least its recovery audit contractors (RACs) were. This week, CMS alerted the American Medical Association (AMA) that it has approved the Medicare Region C RAC. The contractor for Region C,  Connolly, is to begin conducting audits of coding for E/M services in physician offices, specifically CPT code 99215. According to the AMA, in the next several weeks Connolly will begin a complex medical review of code 99215 and will be permitted to extrapolate their findings based on a statistical sample of such claims. Connolly is the Medicare fee-for-service RAC contractor who conducts RAC audits in the following states:

  • Ala.
  • Ark.
  • Colo.
  • Fla.
  • Ga.
  • La.
  • Miss.
  • N.M.
  • N.C.
  • Okla.
  • S.C.
  • Tenn.
  • Texas
  • Va.
  • W.Va.
  • Puerto Rico
  • U.S. Virgin Islands

However, it has not yet been announced if all or only a subset of these states and territories will be under review. As of this writing, Connolly has not posted this information and other details of the review on its website. These reviews are expected to begin imminently in Region C and, according to CMS, are likely to be approved in other Medicare regions in the near future. 

The American Academy of Family Physicians, the AMA, and 100 other state and specialty societies sent a letter to CMS in March 2009 strongly opposing RAC audits of E/M services. However, the OIG report apparently encouraged CMS, through its RAC auditors to do otherwise.

So, what's a family physician to do? I would argue that the advice given in my July post still applies:  make sure that your documentation supports the level of E/M services that you are billing to Medicare. If you are subjected to a RAC audit, take some solace in the fact that, according to CMS' FY 2010 Recovery Auditor Report to Congress, 46 percent of the Medicare RAC determinations that were appealed were decided in the provider's favor. That means you have almost a 50/50 chance of prevailing in the long run. Of course, as John Maynard Keynes once observed, "In the long run, we are all dead." Hopefully, the prospects for physicians in this case are a bit more optimistic.

Tuesday Mar 29, 2011

The old "new patient" conundrum

In its most recent Medicare Quarterly Provider Compliance Newsletter (PDF download) the Centers for Medicare and Medicaid Services (CMS) highlighted an issue that apparently continues to be a problem for some physicians. Namely, when is a patient "new" for purposes of billing evaluation and management (E/M) services?

CMS defines a "new" patient in Chapter 12 Section 30.6.7 (PDF download) of the Medicare Claims Processing Manual as "a patient who has not received any professional services, i.e., E/M service or other face-to-face service (e.g., surgical procedure) from the physician or physician group practice (same physician specialty) within the previous 3 years." This is essentially the same definition as in Current Procedural Terminology (CPT), which states, "A new patient is one who has not received any professional services from the physician or another physician of the same specialty who belongs to the same group practice, within the past three years." CPT defines "professional services" as "those face-to-face services rendered by a physician and reported by a specific CPT code(s)." 

A simple way to determine if a patient is new is to ask yourself this question: "Have I (or another physician of my specialty within our group practice) provided a face-to-face service to this patient within the past 3 years?"  If the answer is no, then the patient is new to you for purposes of coding and billing the E/M service that you are providing to him or her.  If the answer is yes, then you must consider the patient established. Determination of whether the patient is new or established should not be made solely on whether the chart presented was new. Coding or charge entry staff should search for past billing records using the patient's social security number and date of birth, and if a billing record is found, contact the appropriate staff to compare the charts and determine if the patient is established. 

While some of your patients may be new, this issue is not, and apparently, it continues to sufficiently confuse some physicians that CMS felt it necessary to remind folks about the definitions involved. CMS issues the Medicare Quarterly Provider Compliance Newsletter to help physicians and their billing staffs understand the claims submission problems found by Medicare contractors and how to avoid certain billing errors and other improper activities when dealing with the Medicare. In light of that, you may want to check your own understanding of the new patient issue and related coding and billing practices, lest this become a compliance issue in your practice. 

Friday Apr 02, 2010

Are you sure this patient is new?

There has long been confusion about whether to report a new or established patient visit when the physician providing the service is new to the group but has seen the patient elsewhere in the last three years or when the patient seen by Dr. A today has been seen by Dr. B of the same group at another of the group's locations.

It is more important than ever to clear up this confusion. Why? The recovery audit contractor for Medicare Region D, which covers 17 states, lists this among the issues that they are investigating. Other RACs and private payers may do the same.

It is easy for an auditor to produce a report showing new patient E/M service codes reported for a given patient. If these reports show that a patient was charged for new patient visits by the same physician or more than one physician in the same group with the same taxonomy number (specialty number) in the past three years, a request for records or, more likely, a request for a refund, may be generated.

How can you stay out of trouble?

First, make sure that everyone choosing E/M service codes in your practice understands the CPT and Medicare guidelines for reporting a new patient E/M service: Interpret “new patient” to mean a patient who has not received any professional services, i.e., evaluation and management (E/M) service or other face-to-face service (for example, surgical procedure), from the physician or another physician of the same specialty in the group within the previous three years. Note that interpreting a diagnostic test, reading an X-ray or EKG, etc., in the absence of an E/M service or other face-to-face service does not affect the designation of a new patient. If a professional component of a procedure is billed but no E/M service or other face-to-face service with the patient has been performed in three years, then the patient remains a new patient for the initial visit.

Next, add a step to your pre-appointment or pre-billing process to review the patient's billing history in your practice management system and determine if any face-to-face service was billed for the patient within the past three years. If a service was provided within the past three years, determine if the patient's service must be reported as established based on the CPT and Medicare criteria.

This decision tree from FPM is a handy reference that can help you determine quickly whether the patient is new or established. Also see Emily Hill's article, which provides additional information on this topic.

Friday Aug 28, 2009

The health plan two-step

Most folks have heard of the Texas two-step. The Texas two-step is danced with two quick steps and two slow steps. 

The health plan two-step is even simpler. It is one step forward and one step backward. The latest demonstration comes courtesy of Aetna

In February 2006, Aetna agreed to pay the full allowed amount for a standard evaluation and management (E/M) service (e.g., a problem-oriented office visit), when billed with modifier 25 and a preventive E/M service. In essence, Aetna agreed to pay the full allowed amount for both services. This was progressive compared to other payers, like CIGNA and UnitedHealthcare, who only pay the acute service at a rate of 50 percent when done at the same encounter as a preventive medicine visit. Of course, some payers completely bundle the acute visit into the preventive visit in that scenario, resulting in payment only for the preventive service.

Anyway, Aetna took the second step of the health plan two-step earlier this month. Effective Aug. 15, 2009, Aetna began applying concurrency rules when two E/M services are billed and allowed with modifier 25, meaning each additional service is paid at less than the full amount. Aetna considers the preventive medicine visit to be the primary service and payable at 100 percent of the allowed amount; it considers the eligible office, or problem-focused, E/M to be the secondary service payable at 50 percent of the allowed amount. Apparently, there are others, like Aetna, who also giveth and taketh away.

The only upside that I can find in this particular dance is that Aetna's policy is now consistent with others' policies, so you have one less exception to remember. On the other hand, as Ralph Waldo Emerson once observed, "A foolish consistency is the hobgoblin of little minds, adored by little statesmen and philosophers and divines." I guess Aetna thinks a lot of it, too.

Monday Apr 27, 2009

Another urban myth about coding

Recently, I received a call from a physician who had heard from a consultant that he should code his levels of evaluation and management (E/M) services based solely on the medical decision making involved.  He asked me if this was true. 

As I have done with other callers asking the same question, I assured him that this was incorrect information.  Current Procedural Terminology (CPT) clearly states that all of the key components (i.e., history, examination, and medical decision making) play a role in selecting a level of E/M service (unless you’re coding on the basis of time because counseling and/or coordination of care dominated the encounter).  For some codes (e.g., new patient office visits), all three key components must meet or exceed the stated requirements to qualify for a particular level of E/M service.  For other codes (e.g., established patient office visits), two of the three key components must meet or exceed the stated requirements to qualify for a particular level of E/M service.  In no case does CPT state that medical decision making, by itself, determines the level of E/M service. 

Medicare policy supports this interpretation.  Section 30.6.1, “Selection of Level of Evaluation and Management Service,” of Chapter 12 of the Medicare Claims Processing Manual states, in part, “Instruct physicians to select the code for the service based upon the content of the service.”  That content includes the history and examination. 

This particular urban coding myth grows out of confusion between medical decision making and medical necessity.  As the same section of the Medicare Claims Processing Manual says, “Medical necessity of a service is the overarching criterion for payment in addition to the individual requirements of a CPT code.”  Using an extreme example, you can perform and document the history, examination and medical decision making necessary for a level-five office visit for a patient with a common cold, but there are not many people who would say that level of service was medically necessary in that circumstance.  In any case, medical necessity is not the same as medical decision making, and medical necessity governs payment, while medical decision making plays but one part in selecting the level of E/M service. 

So the next time someone tells you to code E/M services only on the basis of medical decision making, you might warn them about all the alligators living in the sewer system.

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