CurrentArizona Complete HealthPolicy CC.PP.051

High Complexity Medical Decision-Making

This payment policy governs assignment and documentation requirements for moderate to high complexity Evaluation and Management (E&M) services for providers submitting claims to Arizona Complete Health. It affects physicians and non-physician practitioners across outpatient, inpatient, emergency, observation, nursing facility, domiciliary, and home services.

Policy Summary

PayerArizona Complete Health

PolicyHigh Complexity Medical Decision-Making

Policy CodePolicy CC.PP.051

Change TypeNo material changes

Effective DateJun 20, 2017

Next Review Date

Key ActionEnsure documentation supports extensive diagnoses/options, extensive or complex data review, and high risk of complications, and authenticate records prior to claim submission to avoid payment delays or disallowance.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

2017Policy initial draft year

2018Last annual review year

26%OIG finding: higher-level E&M billed than supported

4Types of medical decision making

CC.PP.021

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High-Intensity E&M Coverage Criteria

High-intensity E&M documentation and coverage criteria

Covered when ALL of the following documentation elements supporting high-complexity medical decision making are present in the medical record:

Documentation demonstrates medical necessity for a high-intensity E&M service (medical decision making of high complexity).

ALL of the following

Number of diagnoses/management options: An extensive number of diagnoses or health management options were addressed. Documentation includes an assessment/clinical impression or diagnosis; for established diagnoses, the status (improved, well controlled, resolving, resolved, inadequately controlled, worsening, failing to improve); for undiagnosed problems, documentation of possible/probable/rule-out diagnoses; initiation or change of treatment; and documentation of referrals or consultations (to whom/where or from whom requested).

ALL of the following

Amount/complexity of data reviewed: An extensive amount and/or complexity of data was reviewed. Documentation includes diagnostic tests/services ordered, performed, planned or scheduled; evidence that those tests were reviewed; documentation of obtaining old medical records or third‑party history; significant findings from old records or family history; discussion of diagnostic testing with another physician; and independent visualization or interpretation of prior images/tracings/specimens.

ALL of the following

Risk of complications/morbidity/mortality: Documentation of high risk related to the presenting problems, diagnostic procedures, or management options. Includes comorbidities/underlying diseases that increase risk, documentation when a surgical or invasive procedure is planned or performed, and documentation or implication of urgent decisions to perform such procedures.

ALL of the following

Provider documentation and authentication: Medical record is intelligible (dated with legible author identity), concise, complete, supports the medical necessity and level billed, and is authenticated (handwritten or electronic signature) by the author prior to claim submission.

Coverage stance

Guidance on High Complexity Medical Decision Making is intended to assist with coverage and payment determinations; it is advisory and not a guarantee of payment.

This payment policy provides guidance to assist in making coverage and payment determinations and administering benefits, but does not constitute a contract or guarantee of payment; coverage and payment are subject to the terms, conditions, exclusions and limitations of the member's plan and applicable state and federal requirements.

State Medicaid provisions take precedence where they conflict with this policy; applicable Medicare National Coverage Determinations (NCDs) and Local Coverage Determinations (LCDs) should be reviewed and take precedence where applicable.

Health Plan may change, amend or withdraw this payment policy at any time; this policy is not medical advice and providers retain professional judgment in treating members.

CPT/HCPCS Coding and Documentation Thresholds

E&M codes mapped to medium-high or high complexity per policyCPT

99205	New patient office/outpatient visit — High complexity
99215	Established patient office/outpatient visit — High complexity
99220	Initial observation care — High complexity
99223	Initial inpatient hospital care — High complexity
99226	Subsequent observation care — High complexity
99233	Subsequent inpatient hospital care — High complexity
99236	Observation or inpatient hospital care — High complexity
99245	Office consultation — High complexity
99255	Inpatient consultation — High complexity
99285	Emergency department visit — High complexity

1–10 of 16

1/2

Referenced code setsmixed

CPT (2017)	Current Procedural Terminology referenced as coding source
HCPCS Level II (2017)	HCPCS referenced as coding source

Documentation thresholds to justify high complexity

Number of diagnoses/management options reviewedAn extensive number of diagnoses or management options must be documented to support high-complexity MDM.

Amount/complexity of data reviewedDocumentation must show an extensive amount and/or complexity of data reviewed (e.g., tests ordered, records obtained, review of prior images or external records).

Risk of complications/morbidity/mortalityThere must be documentation of high risk of complications, morbidity, and/or mortality associated with the presenting problems or planned management.

Consequences of inadequate documentationClaims lacking the above documentation may face payment delay, requests for additional information, or disallowance/post-payment review.

Documented references — code set editions

Provider Documentation, Policy Limits, and Operational Notes

Documentation Required

Document medical necessity and authenticate records before claim submission

To bill high‑intensity E&M services, ensure the medical record documents medical necessity and that: an extensive number of diagnoses/management options were reviewed; an extensive amount and/or complexity of data was reviewed; and there is a high risk of complications and/or morbidity/mortality. Authenticate the record (handwritten or electronic signature) and sign records prior to claim submission to avoid payment delay, disallowance, or post‑payment review.

Document assessment/status of established diagnoses, possible or rule‑out diagnoses, and any initiation/change in treatment.
Document tests ordered/performed and evidence that results or prior records were reviewed or independently interpreted.
Authenticate records with the author’s handwritten or electronic signature before submitting the claim.

Note

Policy provides guidance but does not guarantee payment

This payment policy is a guide to assist in coverage and payment determinations and administering benefits; it is not a contract or a guarantee of payment and is subject to the terms, conditions, exclusions and limitations of the member’s coverage documents and applicable state and federal requirements.

Key Definitions

Definition of Medical Decision Making

DefinitionMedical decision making is the complexity of a physician's work necessary to establish a diagnosis and/or select a health-care management option.

Component — Diagnoses/management optionsDetermined by the number of possible diagnoses or health management options considered during the encounter.

Component — Amount/complexity of data reviewedDetermined by the amount or complexity of medical records, diagnostic testing, or other information that must be reviewed and evaluated.

Component — RiskDetermined by the risk of complications, morbidity, and/or mortality associated with the patient's problems, diagnostic procedures, and management options.

Definition of Evaluation and Management (E&M)

Definition

Policy Summary

PayerArizona Complete Health

PolicyHigh Complexity Medical Decision-Making

Policy CodePolicy CC.PP.051

Change TypeNo material changes

Effective DateJun 20, 2017

Next Review Date

SourceLink

On This Page

CPT edition referencedCurrent Procedural Terminology (CPT), 2017 edition.

HCPCS edition referencedHCPCS Level II, 2017 edition.

Other sources listedCenters for Medicare and Medicaid Services and relevant OIG report cited in references.

Coverage and payment determinations are governed by the member’s evidence of coverage, policy, and applicable law.
The policy is not intended to dictate medical practice or guarantee results.

Denial Risk

Policy may be changed; NCDs/LCDs and state Medicaid take precedence

Health Plan may change, amend or withdraw this payment policy at any time. Where state Medicaid provisions conflict with this policy, state Medicaid provisions take precedence; for Medicare members, applicable NCDs and LCDs must be reviewed and take precedence as applicable.

Health Plan retains the right to revise or withdraw the policy without prior notice.
Follow state Medicaid manuals when state provisions conflict with this policy.
Review applicable Medicare NCDs and LCDs on the CMS website before applying this policy.

Evaluation and Management (E&M) refers to physician–patient encounters that are translated into five‑digit CPT codes for billing purposes.

Settings coveredDifferent E&M codes exist for various patient encounters such as office visits, hospital visits, home visits, nursing facility visits, emergency department encounters, and others.

Levels of careEach encounter type has multiple levels of care (e.g., initial hospital care codes 99221–99223) corresponding to complexity and services rendered.

Definition of 'Health Plan'

Meaning of 'Health Plan''Health Plan' means a health plan that has adopted this payment policy and that is operated or administered, in whole or in part, by Centene Management Company, LLC, or any of such health plan's affiliates, as applicable.

Scope of applicabilityApplies to the Health Plan(s) that adopt this payment policy; effective date is determined by the Health Plan and posting date may differ from the effective date.

Policy roleThis payment policy is a guide to assist in coverage and payment determinations and administering benefits but does not constitute a contract or guarantee of payment.