When Coding, Remember: ‘Necessity’ Is in the Eye of the Beholder

Providers are employing evaluation and management (E/M) code 99214 more than ever—and seeing fewer denials and higher reimbursements than in the past, ultimately. That doesn’t mean it’s open season on the higher level code (and associated higher reimbursements), however; documenting medical necessity sufficiently is still critical to ensuring the code is valid compared with the reigning most common code (99213). Operators must ensure coders understand that while a level 3 visit requires one to three components of history of present illness, level 4 requires four or more. Level 4 also requires at least two systems are covered in the review of systems. In 2015, 99213 was used 104.6 million times, with 99214 a close second at 99.7 million instances. Only 4% of 99214 claims were denied last year. The uptick in successful utilization of 99214 has been attributed partially to the widespread acceptance of electronic health records, which have made it simpler for providers to document every element of a patient encounter.