Overview

This policy is intended to address Evaluation and Management (E/M) services reported using Current Procedural Terminology (CPT®) codes 99201-99350. Each code contains three (3) "key" components: history, examination and medical decision making, which are used as a basis for selecting a level of E/M code that best describes the service rendered to the patient.

The E/M coding section of the CPT® book is divided into broad categories with further sub-categories which describe various E/M service classifications.

The classification of the E/M service is important because the nature of the work varies by type of service, place of service, the patient’s medical status, and other code criteria, along with the amount of provider work and documentation required. The key components appear in the descriptors for most basic E/M codes and many code categories describe increasing levels of complexity.

CPT provides guidelines for the appropriate selection of E/M codes and the required documentation. In addition, CMS published E/M documentation guidelines in 1995 and 1997 for each of the key components of E/M services. 

The documentation of the three components (history, examination and medical decision making) depends on clinical judgment of the provider and the nature of the presenting problem(s). Each of these three components has different levels of complexity. 

This policy describes when E/M records may be requested and the UnitedHealthcare methodology used for medical record review under this policy.

Reimbursement Guidelines

This reimbursement policy explains when medical records may be requested to ensure that the appropriate level of CPT E/M code is reimbursed based on the health care services provided. The code(s) reported by physicians or other health care professionals should best represent the services provided based on the AMA and CMS documentation guidelines.

UnitedHealthcare uses an Optum proprietary scoring tool based on the instructions in the 1995 and 1997 CMD documentation guidelines. Medical records are requested when the data shows a physician or other health care professional has a billing pattern that deviates significantly from their peers. 

The medical record review process takes into consideration CMS documentation guidelines. Based on the record review points are assigned in accordance with the documented medical record. 

Additional Work-up Planned is an element of review which includes a number of diagnoses and management options. The Additional Work-up Planned element contributes to indicating the complexity of a patient based on the clinician’s utilization of diagnostic tests.