Medical Necessity: Not just LCD

Debra L. Patterson, M.D.Medicare Medical Director

TrailBlazer Health Enterprises, LLC

Medical Necessity In The LawMedical 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 DefinedMedical Necessity Defined

Medical Necessity vs. Medicare CoverageMedical 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 CoverageMedical 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 PolicyMedical 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 PolicyMedical Necessity in Medicare Policy

Many (most?) services are paid byMedicare absent of specific writtenmedical necessity policy

• Absence of national or local policy

• Vague, non-specific, or non-inclusive existing national and/or local policy

Medical Necessity DefinedMedical Necessity Defined

Determined largely by clinicians andcoders 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 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

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 It is inappropriate to report to Medicare E/M services at levels Medicare E/M services at levels higher than are medically higher than are medically necessary regardless of the level necessary regardless of the level at which the service is at which the service is documented !documented !

Medical Necessity in Evaluation and Management Services

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 NecessityMedical NecessityThe 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 NecessityMedical 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 NecessityMedical NecessityAcuity 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 NecessityMedical NecessityAcuity 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 NecessityMedical NecessitySeverity 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

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

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 NecessityMedical NecessitySeverity 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 NecessityMedical NecessityPhysical 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 NecessityMedical NecessityComplexity 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 LCDMedical Necessity: Not just LCD

Terry ReevesTerry ReevesInstitutional Compliance OfficerInstitutional Compliance Officer

Office of Institutional ComplianceOffice of Institutional ComplianceHCCA April 2006HCCA April 2006

The 7 Components of an E/M

History History Physical ExaminationPhysical ExaminationMedical Decision MakingMedical Decision MakingCounseling Counseling Coordination of CareCoordination of CareTimeTimeNature of the presenting problemNature of the presenting problem

Nature of the Presenting Problem

9921299212““Usually the presenting problems are selfUsually the presenting problems are self--limited or limited or minorminor””

9921399213““Usually the presenting problems are of low to Usually the presenting problems are of low to moderate severitymoderate severity

99214 99214 ““Usually the presenting problems are of moderate to Usually the presenting problems are of moderate to high severityhigh severity””

9921599215““Usually the presenting problems are of moderate to Usually the presenting problems are of moderate to high severityhigh severity””

How do these look?

9921299212

9921399213

9921499214

9921599215

What is the difference between Chief Complaint and Nature of the Presenting Problem?

Patient presents with a Chief Complaint of Patient presents with a Chief Complaint of ““sore sore throatthroat””..cc: problem focusedcc: problem focused

After history and exam and labAfter history and exam and lab-- the patient has the patient has ““strepstrep”” throat. throat.

Now, what level is the Nature of the Presenting Now, what level is the Nature of the Presenting Problem?Problem?pp: low to moderatepp: low to moderate

Does the level change?

Now, what if this patient was 18 months Now, what if this patient was 18 months old old (and documented)?(and documented)?

CC: problem focusedCC: problem focusedPP: moderate to high severityPP: moderate to high severity

Now, what if this patient has unstable Now, what if this patient has unstable diabetes? (documented)diabetes? (documented)

CC: problem focusedCC: problem focusedPP: moderate to high severityPP: moderate to high severity

Does the level change?

Now, the patient has stable hypertension Now, the patient has stable hypertension which the physician does not address in the which the physician does not address in the documentation of this visit.documentation of this visit.CC: sore throat CC: sore throat PP: strepPP: strep

Does the patientDoes the patient’’s history add to the s history add to the complexity if it is not addressed during this complexity if it is not addressed during this encounter?encounter?

What adds to the Nature of the Presenting Problem?

The complexity of coThe complexity of co--morbidities morbidities that have that have been documentedbeen documented to have clearly influenced to have clearly influenced the physician work (for this encounter) can the physician work (for this encounter) can add to the complexity because they complicate add to the complexity because they complicate the presenting problem(s).the presenting problem(s).

If the coIf the co--morbidities morbidities are listed but not are listed but not documenteddocumented to effect this encounter, they do to effect this encounter, they do not add to the complexity for this level of not add to the complexity for this level of service.service.

What is the correct level?

An established patient presents with An established patient presents with recurrent tennis elbow after recurrent tennis elbow after discontinuing NSAID. The physician discontinuing NSAID. The physician takes a problem focused history, takes a problem focused history, examines the elbow, and recommends examines the elbow, and recommends a different OTC medicationa different OTC medication..

The correct CPT code would beThe correct CPT code would be……

The correct answer is The correct answer is 9921299212because there was a problem because there was a problem focused history, a problem focused focused history, a problem focused exam (only the elbow), a straight exam (only the elbow), a straight forward medical decision making, forward medical decision making, and the presenting problem was and the presenting problem was selfself--limiting or minor.limiting or minor.

What is the correct level?

Add to the complexity…

Patient described that they discontinued the Patient described that they discontinued the NSAID due to GI upset NSAID due to GI upset

Physician had also examined the abdomen Physician had also examined the abdomen Ordered an Upper GI Ordered an Upper GI Documented an expanded history and Documented an expanded history and

physical physical The correct code would then beThe correct code would then be……

The correct answer is The correct answer is 9921399213 because because this is now an expanded problem this is now an expanded problem focused history; an expanded focused history; an expanded problem focused exam was done, problem focused exam was done, medical decision making increased, medical decision making increased, and the presenting problem is now and the presenting problem is now more a low to moderate severity.more a low to moderate severity.

What is this level?

An established patient presents for a An established patient presents for a periodic follow up visit. The patient has periodic follow up visit. The patient has chronic asthma and type 2 diabetes, both chronic asthma and type 2 diabetes, both are stable on current meds. The physician are stable on current meds. The physician takes a history regarding both problems takes a history regarding both problems (expanded problem focused), examines (expanded problem focused), examines the patient, and continues the current the patient, and continues the current meds (medical decision making of low meds (medical decision making of low complexity).complexity).

The correct code would beThe 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 In this same service, if the physician documented a comprehensive history documented a comprehensive history and examination, could they bill a and examination, could they bill a 99215 for this visit?99215 for this visit?

No, the volume/level of detail of the No, the volume/level of detail of the documentation is not the determining documentation is not the determining factor for Level of Service.factor for Level of Service.

Now… how about this one? Mr. Locke is a 70 year old white male who Mr. Locke is a 70 year old white male who

complains of moderate, persistent pain in complains of moderate, persistent pain in his left arm for the past five days. his left arm for the past five days.

The pain radiates from the shoulder toward The pain radiates from the shoulder toward the elbow and wrist. the elbow and wrist.

Each episode lasts about ten minutes. Each episode lasts about ten minutes.

He has some shortness of breath. He has some shortness of breath.

Patient states he fell from a ladder six days Patient states he fell from a ladder six days ago.ago.

Coding with an Electronic Medical Record ……

What information is actually reviewed for this What information is actually reviewed for this Date of Service (DOS)?Date of Service (DOS)?

What information is What information is ““blown inblown in”” from the prior from the prior visits/patient history?visits/patient history?

What information is part of a preWhat information is part of a pre--formatted formatted template?template?

Is the information all Is the information all ““medically necessarymedically necessary”” for for this DOS??????this DOS??????

ExampleDate of Visit 12/20/05Date of Visit 12/20/05

3 year old male here today with the following 3 year old male here today with the following complaints: complaints:

cough, nasal congestion, postcough, nasal congestion, post--nasal dripnasal drip, , rhinorrhea, yellow and fever present last rhinorrhea, yellow and fever present last week, treated by outside doctor (?ER) week, treated by outside doctor (?ER) started on Augmentin and now having started on Augmentin and now having diarrhea and really bad diaper rash . Has diarrhea and really bad diaper rash . Has pus draining from left ear. Also with:pus draining from left ear. Also with:

fever:improving, but still presentfever:improving, but still presenteye problems: noneeye problems: noneear problems: complaints of tugging from ear problems: complaints of tugging from left earleft earthroat problems:nonethroat problems:noneabdominal pain: noneabdominal pain: nonevomiting: nonevomiting: nonediarrhea: yes since starting abx, no blood diarrhea: yes since starting abx, no blood hydration concerns: hydration concerns: slightly decreased po slightly decreased po intakeintake; ; normal urinary outputnormal urinary outputactivity level: mildly decreasedactivity level: mildly decreasedsick contacts: nonesick contacts: none

Date of Visit 1/20/06

3 year old male here today with the following complaints:

cough, nasal congestion ,post-nasal drippresent for 3 day(s) occurring primarily at any time. Also with:

fever: improving, but still presenteye problems: noneear problems: complaints of tugging from left earthroat problems:noneabdominal pain: none vomiting: nonediarrhea: none hydration concerns: slightly decreased po intake; normal urinary outputrecent illnesses: h/o ear infections with tubes in placeactivity level: normalsick contacts: attends daycare

ExampleDate of Visit 12/20/05Date of Visit 12/20/05PHYSICAL EXAMPHYSICAL EXAM

Temp (Src) 98.3 (Tympanic) | Wt (32 lbs)Temp (Src) 98.3 (Tympanic) | Wt (32 lbs)General: uncooperative, uncomfortableGeneral: uncooperative, uncomfortableEyes: pupils equal, round, reactive to light Eyes: pupils equal, round, reactive to light and conjunctiva clearand conjunctiva clearEars: Ears: R TM: PE tube(s) present, patent and R TM: PE tube(s) present, patent and dry, L TM: PE tube(s)dry, L TM: PE tube(s) present with purulent present with purulent drainagedrainageNose: purulent dischargeNose: purulent dischargeThroat: moist mucous membranes, normal Throat: moist mucous membranes, normal tonsils without erythema, exudates or tonsils without erythema, exudates or petechiaepetechiaeNeck: supple and no lymphadenopathyNeck: supple and no lymphadenopathyLungs: Positive for expiratory wheezes: Lungs: Positive for expiratory wheezes: bilaterally, diffuselybilaterally, diffuselyHeart: regular rate and rhythm, no murmurHeart: regular rate and rhythm, no murmurAbdomen: normal bowel sounds, soft, nonAbdomen: normal bowel sounds, soft, non--tender, nontender, non--distended, no distended, no hepatosplenomegaly or masseshepatosplenomegaly or massesSkin: Skin: pink, warmpink, warm, diaper rash has little red , diaper rash has little red bumps all around area, bumps all around area, no ecchymosisno ecchymosisRapid Strep Result: not needed todayRapid Strep Result: not needed today

Date of Visit 1/20/06PHYSICAL EXAMPHYSICAL EXAMTemp (Src) 98.4 (Tympanic) (32 lbs) Temp (Src) 98.4 (Tympanic) (32 lbs) General: alert, active, in no acute General: alert, active, in no acute distressdistressEyes: pupils equal, round, reactive to Eyes: pupils equal, round, reactive to light and conjunctiva clearlight and conjunctiva clearEars: Ears: R TM: PE tube(s) present, patent R TM: PE tube(s) present, patent and dry, L TM: PE tube(s) presentand dry, L TM: PE tube(s) present, patent , patent and a couple of drops of fluid coming and a couple of drops of fluid coming from tubefrom tubeNose: clear dischargeNose: clear dischargeThroat: clear postThroat: clear post--nasal drainage nasal drainage presentpresentNeck: supple and no lymphadenopathyNeck: supple and no lymphadenopathyLungs: clear to auscultationLungs: clear to auscultationHeart: regular rate and rhythm, no Heart: regular rate and rhythm, no murmurmurmurAbdomen: normal bowel sounds, soft, Abdomen: normal bowel sounds, soft, nonnon--tender, nontender, non--distended, no distended, no hepatosplenomegaly or masseshepatosplenomegaly or massesSkin: Skin: pink, warmpink, warm, no rashes, , no rashes, no no ecchymosisecchymosisRapid Strep Result: not needed todayRapid Strep Result: not needed today

Example

Date of Visit 12/20/05Date of Visit 12/20/05ASSESSMENTASSESSMENT

Tube OtitisTube OtitisCandidal RashCandidal RashDiarrheaDiarrhea

PLANPLAN

Plenty of rest and increase liquids.Plenty of rest and increase liquids.Acetaminophen, ibuprofen as Acetaminophen, ibuprofen as directed.directed.floxin bidfloxin bid 55--7 days to left ear7 days to left earnystatin cream apply qid prnnystatin cream apply qid prnOmnicef bid 5 daysOmnicef bid 5 days

Date of Visit 1/20/06ASSESSMENT

Tube otitisUri

PLAN

Plenty of rest and increase liquids.Acetaminophen, ibuprofen as directed.floxin bidz-cof dm

The documentation should not contradict the level of service!

““patient was eating a sandwich and patient was eating a sandwich and complaining about the TV channel complaining about the TV channel selectionselection”” with critical care ER visitwith critical care ER visit

““child was happy and playing comfortablychild was happy and playing comfortably””with a high level E/M visitwith a high level E/M visit

Questions?Questions?