Reminder: High Complexity Medical Decision Making Policy

Date: 02/24/22

As part of Louisiana Healthcare Connections commitment to ensure that we comply with industry standards, we continually review and update our payment and utilization policies. Louisiana Healthcare Connections would like to remind providers to reference policy LA.PP.51: EM Medical Decision Making (PDF) for important information when providing care to our members.

The purpose of this policy is to discuss the appropriate assignment of moderate to high complexity E&M services with an emphasis on medical decision making as a key component of the assignment process. 

As a result of this policy change, LHCC expects that a provider who bills a high intensity E&M service is either treating a very ill patient or the physician was required to review an extensive amount of clinical data to determine the best health management option. To ensure proper reimbursement when billing high intensity E&M codes, providers must show documentation that supports medical necessity and:

1. An extensive number of diagnoses or management options reviewed;
2. An extensive amount and/or complexity of data reviewed;
3. High risk of complications and/or morbidity and mortality.

Physicians should not submit a CPT code for a higher intensity E&M service if the circumstances surrounding the physician-patient encounter do not support medical decision making of moderate to high complexity.

Providers who do not adhere to the requirements outlined in the policy may experience a delay in claims payment, a disallowance of payment related to a request for additional information from the provider, and/or a request to review additional medical records for medical necessity or post payment medical record review.

Providers are encouraged to review the policy (PDF) for additional information.