CPP-014_em-level-selection_v4.2.md
15 criteria read out of 3 pages, classified by layer, each carrying the page it came from. Reconciled against CPP-014 v4.2.
Review
- Validated
- In review
- Approved
- Rejected
- Published
Front matter, as read
Library criteria, traced
Each criterion the library asserts for v4.2, beside the sentence in the document that supports it and the page it is on.
Level 5 for an established patient (99215) requires high-complexity medical decision making, or documented total time in the range published for the code.
Where the record supports a lower level than the one billed, the claim is repriced to the level the record supports.
The extractor found no sentence in this document that supports this criterion. That is a question for a reviewer, not a verdict: the parser is not a model, and a paraphrase it cannot follow reads exactly like a criterion the document never carried.
Detail beyond the summary
Sentences in the document that no library criterion summarises. Most of these are not gaps — the library is a summary and the document is the source — but this is where a rule that never made it into the summary would show up.
When the level billed for an office or outpatient visit is supported by the record, and what the record has to contain to support it.
Time-based selection now requires total practitioner time recorded on the
different date does not support selection by time.
Level is selected by medical decision making or by total time on the date of the encounter.
History and examination do not drive level selection.
It does not by itself support the moderate or high complexity that a level 4 or level 5 problem-oriented visit requires.
Where a problem was addressed at a preventive visit, the record must show the problem, the data reviewed, and the risk considered.
The recoverable amount is the difference between the allowable for the billed level and the allowable for the supported level.
5 more below, in the full list.
Coding rule — a layer of the determination
History and examination do not drive level selection.
Level 5 for an established patient (99215) requires high-complexity medical decision making, or documented total time in the range published for the code.
It does not by itself support the moderate or high complexity that a level 4 or level 5 problem-oriented visit requires.
This is the payer-side counterpart of up-coding: the remedy for a level billed above the record is a down-code to the level the record carries, not a refusal to pay for a visit that happened.
Clinical evidence — a layer of the determination
When the level billed for an office or outpatient visit is supported by the record, and what the record has to contain to support it.
Time-based selection now requires total practitioner time recorded on the
Level is selected by medical decision making or by total time on the date of the encounter.
Where a problem was addressed at a preventive visit, the record must show the problem, the data reviewed, and the risk considered.
Payment consequence — a layer of the determination
Where the record supports a lower level than the one billed, the claim is repriced to the level the record supports.
The recoverable amount is the difference between the allowable for the billed level and the allowable for the supported level.
Where the amount paid exceeded the allowable for the billed level, the excess above the allowable is recoverable in addition, and is a pricing finding rather than a coding one.
The two are reported separately on the notice.
Provider dispute
A provider disputing a finding under this policy may submit the encounter note for the date of service.
Where the note documents the decision making or the total time the billed level requires, the finding is withdrawn.
Unclassified
different date does not support selection by time.
Every criterion above carries the page it was read from. Nothing here is asserted without one, which is the same rule the findings follow.