The Coding Corner Archives

Coding Corner - May 2019 Edition

The Importance of Understanding Medical Necessity

Medical necessity documentation, or lack of it, is one of the most common reasons for claim denials. For a service to be considered medically necessary, it must be reasonable and necessary to diagnosis or treat a patient’s medical condition. When submitting claims for payment, it is the diagnosis codes reported with the service that tells the payer “why” a service was performed. The diagnosis reported can be the determining factor in supporting or not supporting the medical necessity of the procedure.


  • If the patient came in with an earache and was diagnosed with Otitis Media (H66.91), and the provider billed for a chest x ray, insurance would not pay for it. This is because it is not medically necessary to perform a chest x ray on a patient who is not having any breathing or chest related symptoms or problems.
  • Medical necessity is based on “evidence based clinical standards of care”. This means that there is evidence to support a course of treatment based on a set of symptoms or other diagnostic results.
  • Not all diagnoses for all procedures are considered medically necessary. CMS (Centers for Medicare and Medicaid Services) and also commercial payers have coverage policies that specify the diagnosis codes that support medical necessity for certain procedures.
  • It is important to note that a diagnosis code should never be altered to match one of the diagnosis codes listed in a coverage policy as supporting medical necessity. The diagnosis code submitted must be supported and reflected in the medical documentation. It would be inappropriate to report a diagnosis just because it is on an approved list of diagnosis codes that meet medical necessity by a payer.

Medical Necessity and Evaluation and Management Services:

  • Per CMS; Medical necessity of a service is the overarching criterion for payment in addition to the individual requirements of a CPT code. It would not be medically necessary or appropriate to bill a higher level of evaluation and management service when a lower level of service is warranted. The volume of documentation should not be the primary influence upon which a specific level of service is billed.
  • It may be appropriate to perform a highly detailed history and physical even when the patient presents with an uncomplicated problem and no workup is planned. However, in these cases it is best to base the final E/M code selection on the level of medical necessity, even if a coding tool suggests a higher level of service based on what is documented.
  • Medical necessity documentation from a physician and/or provider should include the following:
  • Severity of the “signs and symptoms” or direct diagnosis exhibited by the patient. This is the diagnosis driver, and multiple diagnoses may be involved.
  • Probability of an adverse or a positive outcome for the patient, and how that risk equates to the diagnosis currently being evaluated. This is the medical risk vs. gain.
  • Need and/or availability of diagnostic studies and/or therapeutic intervention(s) to evaluate and investigate the patient’s presenting problem or current acute or chronic medical condition.

Providers should continually enhance their documentation to improve overall coordination between medical record, coding accuracy, payer reimbursement. Up front communication with the billing team and/or insurance payers will help avoid claim denials. Some examples of what payers look for when reviewing support of medical necessity include:

  • Treatment is consistent with symptoms or diagnosis of the illness, injury, or symptoms under review by the provider of care.
  • Treatment is necessary and consistent with generally accepted professional medical standards (not experimental or investigational).
  • Treatment is not furnished primarily for the convenience of the patient, the attending physician, or another physician of supplier.
  • Treatment is furnished at the most appropriate level that can be provided safely and effectively to the patient, and is neither more or less than what the patient is requiring at that specific point in time.
  • The disbursement of medical care and/or treatment must not be related to the patient’s or the payer monetary status or benefit.

Medical necessity is the base to support the service provided. CMS provides a specific definition under the Social Security Act: “no Medicare payment shall be made for items or services that are not reasonable and necessary for the diagnosis or treatment of illness or injury or to improve the functioning of a malformed body member.”

Please contact Shawn Bromley at 978-236-1704 or if you have questions related to coding, billing and/or medical necessity documentation requirements.

Coding Corner - April 2019 Edition

E/M Coding and the Documentation Guidelines: Putting It All Together:

Key components that make up an established patient visit are History (HPI), Exam and Medical Decision Making (MDM). An established patient visit will need to have 2 of 3 key components and must meet medical necessity.

The underlying problem for wrong billing of these services includes the following:

  • Lack of understanding on how the coding system for E/M works
  • Inaccurate and incomplete documentation to support the code billed
  • Supporting medical necessity
  • Downcoding (documentation supports a higher level service code)
  • Upcoding (documentation supports a lower level service code)c

Comparison coding and billing for level 99213 and 99214:

Click to enlarge/print

Many providers are consistently undercoding for their services because they have a limited understanding of the rules.  A working knowledge of the E/M coding is the best way to ensure optimal compliance and avoid inadvertent undercoding. Providers who understand the process of E/M documentation can optimize a higher rate of return for their services. If you know how to accurately bill for your services, there is a better chance you will get paid for what you really do.

Changes Coming in 2021

  • New rules for coding based on time
  • Code based on MDM alone
  • New blended payment structure for new and established office patients
  • New minimum documentation threshold for new and established office patients
  • New G code for increased reimbursement for primary care physicians
  • New G code for increased reimbursement for non-procedural specialty care services
  • New outpatient prolonged services code with decreased time threshold
  • A great resource for E/M coding guidance is:

Please contact Shawn Bromley at or 978-236-1704 if you have questions regarding E/M coding and billing.

Coding Corner - March 2019

Coding News from NEPHO
The Centers for Medicare & Medicaid Services (CMS) and the Office of Inspector General (OIG) recommend that health care providers routinely enlist independent parties to audit coding practices. Chart audits are a way to obtain feedback regarding your coding program and help in measuring quality.

Although the goals may generally be the same, coding audits can differ in several ways, including methodology type, accuracy definitions, and cost.

Coding Audit Methodologies
Coding audits can be retrospective, which is a review of submitted claims, or prospective, an analysis of pre-billed claims. They can also be random, targeted, or a mix of both, and a code-for-code or full-record analysis.

Establishing a regular external coding audit will have a high return on investment (ROI), helping you maintain the best coding practices for the well-being of your practice. Most importantly, it will help identify potential coding and documentation problems and reduce risk of lost revenue from denials.

Coding Audits Help To:

  • Determine if day to day operating procedures are compliant with current regulations
  • Prevent non-compliance issues from occurring
  • Reduce potential for over or underpayments
  • Reduce risk of improper documentation
  • Minimize risk of fraud
  • Ensure compliance with Medicaid and Medicare standards
  • Address areas of coding education opportunity

NEPHO Coding Audit Findings:
In an ongoing effort to ensure accuracy and compliant coding NEPHO performed an outpatient service chart audit review on three NEPHO physician practices. The findings addressed areas of opportunity for provider education. A trend identified included missing preventative screening ICD-10 diagnosis codes that were released October 1, 2018.  The initial review was done in January 2019 and follow-up review was completed in February 2019. The follow-up coding review found that all 3 practices had improved with capture of the new ICD-10 diagnosis codes for screening encounters.

 Z00-Z99 Factors influencing health status and contact with health services

  • 81 Encounter for examination and observation of victim following forced sexual exploitation (ruled out)
  • 82 Encounter for examination and observation of victim following forced labor exploitation (ruled out)
  • 89 Encounter for examination and observation for other specified reasons (ruled out)
  • 30 Encounter for screening examination for mental health and behavioral disorders, unspecified
  • 31 Encounter for screening for depression
  • 32 Encounter for screening for maternal depression
  • 39 Encounter for screening examination for other mental health and behavioral disorders
  • 40 Encounter for screening for unspecified developmental delays
  • 41 Encounter for autism screening
  • 42 Encounter for screening for global developmental delays (milestones)
  • 49 Encounter for screening for other developmental delays
  • 821 Contact with and (suspected) exposure to Zika virus
  • 83 Immunization not carried out due to unavailability of vaccine
  • 430 Family history of elevated lipoprotein(a)
  • 438 Family history of other disorder of lipoprotein metabolism and other lipedemia

Please contact Shawn Bromley at  and/or 978-236-1704 if you would like to have a coding audit performed at your practice or have questions related to coding.

Coding Corner - February 2019 Edition

CPT Coding and Billing Updates for 2019
Here are the most recent 2019 coding updates that physician’s should be aware of to ensure accuracy in coding and billing for MRI Breast Exams and new codes of Chronic Care Management.

MRI-Based Breast Exams Contrast Updated Codes:
The 2019 change deleted codes 77058 and 77059 and resulted in an expansion associated with four codes:

  • 77046: Unilateral MRI breast exams without contrast
  • 77047: Bilateral MRI breast exams without contrast
  • 77048: Unilateral MRI breast exams, with/without contrast
  • 77049: Bilateral MRI breast exams, with/without contrast

    Codes 77046
     and 77047 encompass computer-aided detection (CAD), including CAD real-time lesion detection, characterization and pharmacokinetic analysis. This change has eliminated the need to separately add the HCPCS code 0159T for situations involving CAD.

New Code for Chronic Care Management:
CPT code updates for 2019 include chronic care management (CCM). This update allows providers to bill for at least a half hour of their time.

  • 99491: Chronic care management services provided personally by a physician or other qualified healthcare professional for at least 30 minutes.
  • This code is billed for CCM coordination sessions that are more than 20 minutes but less than an hour.

Coding Corner - January 2019 Edition

Modernizing Medicare Physician Payment by Recognizing Communication
Technology-Based Services

  • CMS has issued its final 2019 Physician Fee Schedule and Quality Payment Program, opening the door to reimbursement for connected care services that enable providers to manage and coordinate care at home. The changes are focused on three new CPT codes that separate Remote Patient Monitoring (RPM) services from telehealth.

The new CPT codes are:

  • CPT code 99453:“Remote monitoring of physiologic parameter(s) (e.g., weight, blood pressure, pulse oximetry, respiratory flow rate), initial; set-up and patient education on use of equipment.”
  • CPT code 99454:“Remote monitoring of physiologic parameter(s) (e.g., weight, blood pressure, pulse oximetry, respiratory flow rate), initial; device(s) supply with daily recording(s) or programmed alert(s) transmission, each
    30 days.”
  • CPT code 99457:“Remote physiologic monitoring treatment management services, 20
    minutes or more of clinical staff/physician/other qualified healthcare professional time in a calendar month requiring interactive communication with the patient/caregiver during the month.”
  • CMS has finalized two newly defined physician’s services utilizing communication technology. These two services are the brief communication technology based service, or virtual check in (HCPCS code G2012), and the remote evaluation of recorded video and/or images submitted (HCPCS code G2010). These services will allow practitioners to decide whether an office visit or other medical service is needed, improving efficiency and convenience for both the practitioner and beneficiary.
  • HCPCS code G2012: CMS states the code allows “audio-only real-time telephone interactions in addition to synchronous, two-way audio interactions that are enhanced with video or other kinds of data transmission.”  (Note: telephone calls that involve only clinical staff cannot be billed using HCPCS code G2012 since the code explicitly describes (and requires) direct interaction between the patient and the billing practitioner.)
  • HCPCS code G2010: CMS defines this code as; remote evaluation of recorded video and/or images submitted by an established patient.

Evaluation and Management (E/M) 2019 Documentation Updates

  • Beginning January 1, 2019, Medicare will allow ancillary staff to perform and record the chief complaint and history of present illness.
  • Additionally, for established patient office/outpatient visits, when the medical record already contains relevant information, Medicare will allow physicians to focus their documentation on what has changed since the last visit, or on pertinent items that have not changed, and not re-record the defined list of required elements. Physicians will still need to review prior data, update it as necessary, and indicate in the medical record that they have done so.
  • These updates were approved to help improve physician’s workflow to provide more focus on the patient during the office visit.
  • CMS has delayed additional E/M additional documentation changes until 2020 and 2021. Updates will be made available as more information is released from CMS.

Contact Shawn Bromley at or 978-236-1704 if you are interested in more information regarding the new Telehealth services or need additional guidance on the updated E/M documentation requirements.

Coding Corner - December 2018 Edition

ICD-10- CM Diagnosis Codes Reset January 1, 2019

  • A major component of the Hierarchical Condition Categories (HCCs) model is that the individual HCCs are only valid for one year. Regardless of the HCCs fundamental chronicity, on January 1, 2019 the patient’s HCC listing will be blank.
  • For example, a patient with diabetes with complications would need to have a face-to-face encounter with a provider where diabetes is discussed and documented for the appropriate
    HCC to be reported in the new base year.
  • There are two important aspects to remember when HCC coding:
  • Analyzing health record documentation to identify reportable conditions
  • Accurately assigning ICD-10-CM codes to these conditions
  • Providers and risk adjustment professionals need to work together to ensure quality and thorough documentation of patient conditions to support risk adjustment and quality reporting initiatives. With such an emphasis on yearly code capture, provider education becomes a higher priority early in the year to prevent the loss of HCC diagnosis.
  • The NEPHO will be working to educate providers beginning early 2019 to help continue efforts to impact the patient’s health status.
  • The following coding education will be a focus for 2019:
  • Risk Adjustment Accurate Documentation and Coding Practices
  • Importance of Risk Adjustment
  • Risk Adjustment Auditing and Monitoring
  • The NEPHO will be working with providers directly to address education opportunities and to ensure accurate coding and reporting of HCCs is continued through the year. Working together can help ensure compliance and optimal financial results under HCC risk adjustment contract models.
  • Please reach out to NEPHO directly if you would like to review risk adjustment education opportunities for your practice. Contact Shawn Bromley at or call 978-236-1704.


Coding Corner - November 2018 Edition