Definitions

Additional Work-up Planned 

Any testing/consultation/referral that is being done beyond that Encounter to assist the provider in medical decision making.

Encounter

Interaction between a covered member and a health care provider for which evaluation and management service or other service(s) are rendered and results in a claim submission

Questions and Answers 

1 Q: When a separate written report for diagnostic tests/studies is prepared by the same individual performing the E/M service in an ER/ED place of service, should this be considered as a factor in the E/M code selection?  

A: No. Any specifically identifiable procedure reported separately from the E/M service should not be considered in the selection of E/M service level reported. For example, a patient presents to the ER/ED with chest pain and an EKG is performed. The EKG is normal; the attending provider determines that the patient has angina and provides a prescription. This would NOT be considered Additional Work-Up Planned because the test was performed and a diagnosis was made during the ER/ED Encounter. If another provider other than the attending provider (such as a cardiologist or radiologist) bills the CPT code for the interpretation, then 2 points are scored because the attending provider is not billing for the interpretation separately.

2 Q: Will UnitedHealthcare require medical records for all reported E/M services? 

A: No. UnitedHealthcare requests medical records when the data indicates a physician or other health care professional has a billing pattern that deviates significantly from their peers. 

3 Q: What if the Encounter doesn’t require Additional Work-up Planned but does require high complexity medical decision making (MDM)? 

A: The provider may submit medical records for review. Consideration will be given to the medical record provided. The Additional Work-up is a component of the number of diagnoses and management options. There are two other elements – amount/complexity of data and the table of risk which contribute to the medical decision making element. CPT also notes that when counseling and/or coordination of care dominates more than 50% of the encounter with the patient and/or family, then time shall be considered the key or controlling factor to qualify for a particular level of E/M services. 

4 Q: How does the policy apply to Electronic Health Record use? 

A: While there is no prohibition on the use of proprietary templates, documentation from either an electronic health record (EHR) or hard-copy that appears to be cloned (selected information from one source and replicated in another location by copy-paste methods) from another record, including but not limited to history of present illness (HPC), exam, and MDM, would not be acceptable documentation to support the claim as billed. The documentation guidelines apply to any medical record produced. .