Dear Cari…The Concept of “meets or exceeds”

E/M Codes | The Concept of  “meets or exceeds”
Dear Cari,

I am really struggling with understanding the concept of “meets or exceeds” when it comes to determining E/M codes. Can you help me sort things out?

Going Crazy in Galveston

Dear Going Crazy,

You’re not alone in meeting with difficulty grasping the concept of “meets or exceeds” in relation to E/M coding. This idea requires some serious mental juggling in order to get it straight. Hopefully, the information below will shed some light on things for you.

The concept of meet or exceeds is basically the equivalent of the mathematical concept of greater than or equal to. First, you must remember that we want to assign the highest possible E/M code in order to make sure we are getting the maximum reimbursement entitled to by the physician. In order to assign the highest E/M code possible 2 out of 3 or 3 out of 3 key components (depending on the category of E/M code) are used to determine the E/M code (i.e. history, exam and MDM) must be met (be equal to) or exceeded (be greater than) by the levels of the key components found in the documentation in the patient’s record.

Here is an example:
Category – Outpatient office visit, new patient. (requires meet or exceed 3 out of 3 key components)

After reviewing our documentation we have determined that the levels of the three key components for this patient’s visit are as follows:
History = Comprehensive
Exam = Detailed
MDM = High

So, what is the highest code we can assign from the outpatient office visit, new patient, category of E/M codes, keeping in mind that 3 out of the 3 key components that determine the E/M code must be met or exceeded by the levels of the key components found in the documentation?

Documented key component levels Requirements for 99203
History = Comprehensive (exceeds detailed) Detailed
Exam = Detailed (meets detailed) Detailed
MDM = High (exceeds low) Low

The answer is 99203 because the level for the key component of examination is detailed which meets the required examination level of detailed for code 99203 and the level for the key component of history is comprehensive which exceeds the required history level of detailed for code 99203 and the MDM level is high which exceeds the required MDM level of low for code 99203. This means we have 3 key components out of 3 whose levels meet or exceed the levels of the key components required for code 99203.

Now, if you chose code 99202 for the E/M code, the level of all 3 components would be met or exceeded, but you would not be assigning the highest possible E/M code and this would mean missed reimbursement for the physician.

You can’t assign a code of 99204 because the level of the key component of exam that is required to assign code 99204 is comprehensive and the level of the exam found in the documentation was only detailed. A detailed exam does not meet or exceed the required exam level of comprehensive for code 99204. So, we can’t meet or exceed all 3 out of 3 key
component levels.

I hope this helps!

Cari Greenwood, CCS, CPC
CS Student Support Team

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