This policy is intended to address Evaluation and Management (E/M) services reported using Current Procedural Terminology (CPT®) codes 99201-99350. Each code contains three (3) "key" components: history, examination and medical decision making, which are used as a basis for selecting a level of E/M code that best describes the service rendered to the patient.
The E/M coding section of the CPT® book is divided into broad categories with further sub-categories which describe various E/M service classifications.
The classification of the E/M service is important because the nature of the work varies by type of service, place of service, the patient’s medical status, and other code criteria, along with the amount of provider work and documentation required. The key components appear in the descriptors for most basic E/M codes and many code categories describe increasing levels of complexity.
CPT provides guidelines for the appropriate selection of E/M codes and the required documentation. In addition, CMS published E/M documentation guidelines in 1995 and 1997 for each of the key components of E/M services.
The documentation of the three components (history, examination and medical decision making) depends on clinical judgment of the provider and the nature of the presenting problem(s). Each of these three components has different levels of complexity.
This policy describes when E/M records may be requested and the UnitedHealthcare methodology used for medical record review under this policy.
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Q: When a separate written report for diagnostic tests/studies is prepared by the same individual performing the E/M service in an ER/ED place of service, should this be considered as a factor in the E/M code selection?
A: No. Any specifically identifiable procedure reported separately from the E/M service should not be considered in the selection of E/M service level reported. For example, a patient presents to the ER/ED with chest pain and an EKG is performed. The EKG is normal; the attending provider determines that the patient has angina and provides a prescription. This would NOT be considered Additional Work-Up Planned because the test was performed and a diagnosis was made during the ER/ED Encounter. If another provider other than the attending provider (such as a cardiologist or radiologist) bills the CPT code for the interpretation, then 2 points are scored because the attending provider is not billing for the interpretation separately.
Q: Will UnitedHealthcare require medical records for all reported E/M services?
A: No. UnitedHealthcare requests medical records when the data indicates a physician or other health care professional has a billing pattern that deviates significantly from their peers.
Q: What if the Encounter doesn’t require Additional Work-up Planned but does require high complexity medical decision making (MDM)?
A: The provider may submit medical records for review. Consideration will be given to the medical record provided. The Additional Work-up is a component of the number of diagnoses and management options. There are two other elements – amount/complexity of data and the table of risk which contribute to the medical decision making element. CPT also notes that when counseling and/or coordination of care dominates more than 50% of the encounter with the patient and/or family, then time shall be considered the key or controlling factor to qualify for a particular level of E/M services.
Q: How does the policy apply to Electronic Health Record use?
A: While there is no prohibition on the use of proprietary templates, documentation from either an electronic health record (EHR) or hard-copy that appears to be cloned (selected information from one source and replicated in another location by copy-paste methods) from another record, including but not limited to history of present illness (HPC), exam, and MDM, would not be acceptable documentation to support the claim as billed. The documentation guidelines apply to any medical record produced.