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Extraction

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.

Validated

Review

Extracted and structurally checked. Nobody has read it yet.
  1. Validated
  2. In review
  3. Approved
  4. Rejected
  5. Published

Where this is a stand-in. The states and the transitions are the Knowledge Center's. What is not here is the machinery they rest on: the platform requires a second identity to approve — an author may not approve their own change — and the approver signs the content hash they were shown. This demo has one operator, holds review rounds in memory for the life of the process, and signs nothing.

Approval records that a reviewer read the extraction and agrees it represents the document. It does not write a policy version — every version in the library already exists and this document names one, so the extractor reconciles into that version rather than minting one. An extractor is the wrong thing to be editing effective dates.

Front matter, as read

Policy and version CPP-014 v4.2 — Evaluation and management level selection
Effective, per the document 2026-01-01 read as “1 January 2026”
Effective, per the library 2026-01-01 agrees
Supersedes v4.1
Owner Payment Integrity Policy Committee
Applies to All lines of business — all states
External basis CPT E/M guidelines · CMS Claims Processing Manual ch. 12 §30.6

Library criteria, traced

2 of 3

Each criterion the library asserts for v4.2, beside the sentence in the document that supports it and the page it is on.

Traced Level 5 (99205 / 99215) requires high-complexity medical decision making, or documented total time in the code's range. 0.73

Level 5 for an established patient (99215) requires high-complexity medical decision making, or documented total time in the range published for the code.

Coding rule page 2 “3.1 Level selection”
Traced Where the record supports a lower level, the claim is repriced to that level rather than denied in full. 0.58

Where the record supports a lower level than the one billed, the claim is repriced to the level the record supports.

Payment consequence page 2 “3.3 Repricing rather than denial”
Not traced A routine examination diagnosis without a documented problem addressed does not by itself support a level 4 or 5.

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

13

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.

Clinical evidence page 1 0.60

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.

Clinical evidence page 1 0.30

Time-based selection now requires total practitioner time recorded on the

Unclassified page 1 0.00

different date does not support selection by time.

Clinical evidence page 2 0.46

Level is selected by medical decision making or by total time on the date of the encounter.

Coding rule page 2 0.67

History and examination do not drive level selection.

Coding rule page 2 0.33

It does not by itself support the moderate or high complexity that a level 4 or level 5 problem-oriented visit requires.

Clinical evidence page 2 0.50

Where a problem was addressed at a preventive visit, the record must show the problem, the data reviewed, and the risk considered.

Payment consequence page 2 0.76

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

4

What the coding rule requires — level, sequencing, units, modifiers.

page 2 “3.1 Level selection” 0.67

History and examination do not drive level selection.

classified on: levelsection “3.1 Level selection”
page 2 “3.1 Level selection” 0.50

Level 5 for an established patient (99215) requires high-complexity medical decision making, or documented total time in the range published for the code.

classified on: codelevelsection “3.1 Level selection”
page 2 “3.2 Preventive diagnoses” low confidence 0.33

It does not by itself support the moderate or high complexity that a level 4 or level 5 problem-oriented visit requires.

classified on: level
page 2 “3.3 Repricing rather than denial” 0.58

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.

classified on: codecodinglevel

Clinical evidence — a layer of the determination

4

What the record has to show before the code stands.

page 1 “1. Purpose” 0.60

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.

classified on: recordsupported
page 1 “Two changes take effect on 1 January 2026:” low confidence 0.30

Time-based selection now requires total practitioner time recorded on the

classified on: record
page 2 “3.1 Level selection” 0.46

Level is selected by medical decision making or by total time on the date of the encounter.

classified on: medical decision makingencounter
page 2 “3.2 Preventive diagnoses” 0.50

Where a problem was addressed at a preventive visit, the record must show the problem, the data reviewed, and the risk considered.

classified on: record

Payment consequence — a layer of the determination

4

What it costs, and how the recoverable amount is computed.

page 2 “3.3 Repricing rather than denial” 0.42

Where the record supports a lower level than the one billed, the claim is repriced to the level the record supports.

classified on: repricedsection “3.3 Repricing rather than denial”
page 2 “3.3 Repricing rather than denial” 0.76

The recoverable amount is the difference between the allowable for the billed level and the allowable for the supported level.

classified on: recoverableallowableamountdifference
page 3 “4. Recovery” 0.76

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.

classified on: recoverablepaidallowableamount
page 3 “4. Recovery” low confidence 0.17

The two are reported separately on the notice.

classified on: section “4. Recovery”

Provider dispute

2

How a provider challenges the finding.

page 3 “5. Provider dispute” 0.65

A provider disputing a finding under this policy may submit the encounter note for the date of service.

classified on: disputingprovider disputingsection “5. Provider dispute”
page 3 “5. Provider dispute” 0.46

Where the note documents the decision making or the total time the billed level requires, the finding is withdrawn.

classified on: withdrawnsection “5. Provider dispute”

Unclassified

1

No word in the classifier's vocabulary appeared. A person has to place these.

page 1 “Two changes take effect on 1 January 2026:” low confidence 0.00

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.