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