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Evaluation and Management Codes Drive Medical Necessity

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The 2008 Work Plan was issued by the Office of Inspector General (OIG) on October 1, 2007 ( Plan_FY_2008.pdf). It outlines primary areas that its Office of Audit Services and Office of Evaluations and Inspections will be targeting in 2008—including Medicare Payments for Interventional Pain Management Procedures. The fact is that Medicare and all insurances will increase their examination of your documentation practices for “medical necessity” in 2008. In order to meet such guidelines, you will have to get serious about computerizing your practice with an appropriate pain management–specific EMR system having a proven track record in helping pain management doctors—as opposed to primary care doctors—document medical necessity. The following article by Dr. Ted Arkfeld will help you determine what you need to do in order to document the medical necessity that is crucial for you to be paid for your services.

In the last article, I discussed medical necessity since the OIG 2008 Work plan will focus on pain management clinics. Medical necessity definitions vary from one payer to the next. Fortunately, Medicare—and most Blue Cross and Blue Shield plans—publish their definitions. However, this is not always the case with other group insurances and often lead to high levels of frustration from providers and their billing departments. No matter what their definition may be, if your E/M codes are chosen correctly, you can begin the process of establishing medical necessity.

For some reason, E/M coding remains a misunderstood process, and may lead to downcoding or upcoding to an inappropriate higher level than the documentation can validate. If you are still using exam forms or writing out the history and examination findings in long hand, then you are working way too hard and probably losing insurance reimbursements due to improper coding. Even if you have an electronic medical record system (EMR), you may still be losing revenue since most of these programs let you choose the level of E/M after you have completed the history and examination sections. The problem with these EMR’s is that they are at the back end of the process instead of guiding you from the start through a preset compliant workflow to insure the correct level is reached.

Before we delve into EMR system selection, you still need to understand how to arrive at the appropriate E/M level, and this starts with what constitutes a new, versus established, patient visit.

New and Established Patient Definitions

New Patient. A new patient is one who has not received any professional services from a physician or another physician of the same specialty who belongs to the same group practice, within the past three years

Established Patient. An established patient is one who has received professional services from the physician or another physician of the same specialty who belongs to the same group practice, within the past three years.

Who is Not a New Patient?


  1. Someone who has seen another physician in a group practice of a different specialty, but all physicians use the same tax identification number.
  2. A patient who was previously under care, but who is now involved in either an auto or worker’s compensation case.
  3. Any patient who has been under your care or another physician in your group within the past three years, no matter if they have a new injury or new insurance.

I know this seems pretty straightforward, but unfortunately there has been incorrect information relayed regarding these two very distinct classifications.

Okay, so now you have a clear definition of a new patient and one is waiting right now to be seen by you. What is your next step? How are you currently deciding on what level to go with? Hopefully, you are not basing this decision on time. More on that later, but for now there are five E/M levels, each with subcategories that must be met or exceeded to arrive at the correct coding decision. This is where an EMR system that allows you to proceed with a up front workflow procedure is a must.

E/M Components

The components of E/M are listed below with the first three being key:

1.  History Key
2.  Examination Key
3.  Medical Decision Making Key
4.  Counseling Contributory
5.  Coordination of Care Contributory
6.  Nature of Presenting Problem Contributory
7.  Time Contributory

Each one of these E/M components has subcategories that need to be satisfied in order to meet or exceed a certain level. These subcategories are as follows:

  • Problem Focused
  • Expanded Problem Focused
  • Detailed
  • Comprehensive

History Criteria

History of Present Illness (HPI):

  1. Location
  2. Quality
  3. Severity
  4. Timing
  5. Duration
  6. Context
  7. Mod. Factors
  8. Sign/Symptoms

Review of Systems (ROS):

  1. Constitutional
  2. Eyes
  3. Ears/Nose/Mouth/Throat
  4. Cardiovascular
  5. Respiratory
  6. Gastrointestinal
  7. Genitourinary
  8. Musculoskeletal
  9. Skin
  10. Neurological
  11. Psychiatric
  12. Endocrine
  13. Hematologic/Lymphatic
  14. Allergic/Immunologic

Review of systems must be problem pertinent.
Past Medical, Family & Social History (PFS):

  1. Past Medical History
  2. Family History
  3. Social History

Examination Criteria


  • Three Vital Signs
  • General Appearance


  • Conjunctiva, lids
  • Pupils, irises
  • Opthalmoscopic exam


  • Ext. ears, nose
  • Ext. aud canals, TM’s
  • Hearing assessment
  • Nasal mucosa/septum/turbinates
  • Lips, teeth, gums
  • Oropharynx exam


  • Masses, appearance
  • Thyroid


  • Respiratory effort
  • Percussion of Chest
  • Palpation of Chest
  • Auscultation of lungs


  • Palpation of heart
  • Auscultation of heart
  • Carotid Arteries
  • Abdominal aorta
  • Femoral arteries
  • Pedal pulses
  • Extremities for edema/varicosities

Chest (Breast)

  • Inspection of Breasts
  • Palpation of breast/axillae


  • Mass/tenderness
  • Liver & Spleen
  • Hernia
  • Anus/Rectum
  • Stool Sample (if indicated)


  • Scrotum
  • Penis
  • Prostate
  • Ext. genitalia
  • Urethra
  • Bladder
  • Cervix
  • Uterus
  • Adnexa

Lymphatic (two or more areas required)

  • Neck
  • Axillae
  • Groin
  • Other


  • Gait, station
  • Digits, nails
  • Joints, bones, muscles for each of 6 areas: head/neck, spine/ribs/ pelvis, RUE, LUE, RLE, LLE
  • Inspection/palpation
  • Range of motion
  • Stability/dislocation
  • Muscle strength, tone


  • Inspection rashes, lesions
  • Palpation nodules, tightness


  • Test Cranial Nerves
  • Deep Tendon Reflexes
  • Sensation


Last updated on: January 30, 2012
First published on: January 1, 2008