What is the overarching requirement when selecting E/M codes for payers?

The overarching requirement when selecting Evaluation and Management (E/M) codes for payers is medical necessity. This concept refers to the requirement that the services provided must be clinically justified and appropriate for the patient's condition. Medical necessity ensures that the services billed directly relate to the diagnosis or treatment of the patient's health issues, complying with payer guidelines.

When coding E/M services, a coder must determine whether the services performed meet the payer’s criteria for what constitutes necessary medical care. If the services are not deemed medically necessary, the claim is likely to be denied or require additional scrutiny, regardless of whether the other factors, such as documentation completeness or compliance with coding standards, are in place. Therefore, medical necessity takes precedence, serving as the foundation for coding practices in healthcare billing.

While patient satisfaction and completing documentation are important aspects of providing care and ensuring accurate coding, they do not hold the same weight as medical necessity when it comes to payer requirements. Compliance with coding standards is essential for accurate coding but still takes a backseat to the fundamental requirement of medical necessity.