E/M Weekly Tip: Medical Necessity

Published 08/03/2020

Medical necessity of a service is the overarching criterion for payment in addition to the individual requirements of a CPT code. 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. Documentation must support the level of service reported.

For more information, please visit the Medicare Claims Processing Manual, 100-04, chapter 12, Section 30.6.1 A at CMS website (PDF, 1.1 MB).

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