Evaluation & Management: CMS Overarching Criteria vs CPT/Documentation Guidelines

CMS has implemented the overarching criterion for E/M services which makes it clear that medical necessity is the driving force of the level of service assignment. Specifically, CMS states in their statement of overarching criterion, “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.” (Medicare Claims Processing Manual 30.6.1)

The overarching criteria is subjective, brief and to the point but provides no mechanism to operationalize the guidance. It relies solely on physician’s judgment to document what level of exam or history is required for any condition. The overarching criterion is interpreted as below by many practices – documentation of the key components determined by the nature of presenting problem and medical necessity.

The Documentation Guidelines themselves and the audit tools provide a more objective tool in auditing an E/M note. Using these tools, the level of service is based upon the key components of history, exam and medical decision-making. Some services require all of the three components and audit to the level of the lowest component. Some services require only two of the three key components.

Tip: Physicians do need to use their electronic health records in a way that more clearly documents what happened at the visit and be prudent in copying/ clicking. Medical necessity should guide the physician in terms of the documentation of the key components.

It’s certainly true that for certain code categories, such as new patient, hospital observations and initial hospital care, the lowest level of the three of the key components determines the proper code. But the CPT book is very clear that for established patients, subsequent hospital care, subsequent nursing facility care, and a few other categories, you choose the E/M code based on two out of three components.

Since the CMS overarching criterion is subjective, we advise providers to perform and document only medically necessary services and to choose the E/M level based on CPT Guidelines.

CMS has proposed for the revamping of the E/M guidelines. It sought comments from stakeholders (physicians and non-physicians billing E/M) and Stakeholders have long maintained that both the 1995 and 1997 guidelines are administratively burdensome and outdated with respect to the practice of medicine, stating that they are too complex, ambiguous, and that they fail to distinguish meaningful differences among code levels. In general, stakeholders agree that there may be unnecessary burden with these guidelines and that they are potentially outdated, and believe this is especially true for the requirements for the history and the physical exam.

In response, CMS announced its intention to undertake a multi-year effort—with the input of providers and other stakeholders — to revise the current E/M documentation guidelines. This revision will likely include removal of the history and exam documentation requirements.