# changing level of E/M



## JRae5M (Jul 31, 2018)

I do internal auditing of E/M levels. I was initially asked to do this in order to educate the provider on how to improve documentation in order to better support the billed level of service in the future. The company is now asking me, pre-billing, to place an addendum on the provider's note stating the level of service that I find is supported as written. This is to be done when the provider refuses to change the level of service. I know that the provider is legally responsible for the DX code, but is there an ethical or legal conflict with changing the selected level of service? Is there a conflict with what I am being asked to do? Jacki M., MA CPC-A


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## Pathos (Jul 31, 2018)

I've looked at this topic several times, and I am still not finding clear language which directly omits anyone from amending a patient note, and allowing the provider to sign it. However, the whole point of signing off on a note and with CMS otherwise stringent rules, are to keep the patient note integrity, provider integrity, and comply with ethical standards.

If the provider refuses to change the E/M level, but management is pushing for you to amend and change the code for him/her, then that's the first red flag right there. Yes, the provider is ultimately responsible, and if staff is changing the provider's documentation and coding without an agreement, then there's a compliance issue with that. I would not be willing to do this, and if this is a clinic standard I would take this situation to the compliance officer before going head-to-head with management.


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## thomas7331 (Jul 31, 2018)

I tend to agree - I don't know of anything that really prohibits this information being added to a note, but I think it is inappropriate.  The medical record is for clinical information related to the treatment of the patient.  Although many medical record systems do include CPT and ICD-10 codes, the medical record really is not the proper place for coding or billing information, and certainly not a place to be communicating back and forth about coding discrepancies between provider codes and auditor codes.  I would recommend finding a more appropriate place to communicate these coding changes and doing provider education than in patients' records.


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## sxcoder1 (Aug 1, 2018)

I agree that the medical record is not the place for interoffice billing comments.


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## brookequerry (Aug 8, 2018)

J5Murin said:


> I do internal auditing of E/M levels. I was initially asked to do this in order to educate the provider on how to improve documentation in order to better support the billed level of service in the future. The company is now asking me, pre-billing, to place an addendum on the provider's note stating the level of service that I find is supported as written. This is to be done when the provider refuses to change the level of service. I know that the provider is legally responsible for the DX code, but is there an ethical or legal conflict with changing the selected level of service? Is there a conflict with what I am being asked to do? Jacki M., MA CPC-A



I don't believe that there is anything wrong with correcting the codes on the insurance claim for correct billing. I have a billing system that I document in when correcting codes (based on the providers documentation) pre-billing, so I do not alter the medical record. I work for an FQHC so this might be different for you. I have read that you might need the providers agreement since they are responsible for the billing under their certification. I read that on another comment here on the forum.


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## Pathos (Aug 8, 2018)

If you have a pre-existing agreement with the provider that enables you to change codes with documentation, then that's probably fine. Don't forget that at the end of the day, the provider is held liable for any billings, since the claim is in their name.

The author of this thread mentioned that the provider is refusing to change the code, and is thus not giving permission to change the code. The company of the provider and the author is pushing to have them change the code anyway. I am also curious to learn the reasoning behind the provider refusal. If the argument to change the code is more logically sound than the argument to not change, then that's a side which should be handled. Likewise, if the company's argument is unethical, and the provider is just trying to abide by CMS' rules and regulations. If the latter is the case, then where's the compliance officer?

I get that healthcare companies are under increased financial stress, and they need to find a way to optimize reimbursement. However, this should be done the right way, the first time. Hence why near-perfect compliance is increasingly important.


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## Dorthi (Aug 28, 2018)

*Changing codes*

You can code it down but not a higher level. Only the providers can do that and only clinical stuff can add addendums. 
Now if it is for future education i.e. this note is a level 3 and due to x,y and z this could have been a level 4. Then I can see it, but not to bill out at a higher level of service.


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## angeleve (Sep 21, 2018)

*FQHC Psychiatrist Vs Behavioral Health*

Psychiatrist is considered Behavioral Health? if a patient sees a counselor as a new patient and then they see a psychiatrist (who is an MD a contract employee that we bill for services), is the first visit with the psychiatrist (within the 3 year period) a new or established patient? 

is it an established patient within the counseling/behavioral health services area just as if a dentist and then a hygienist see a patient on two separate days. The second visit would be an established patient (same for a NP and a MD).  Right?

Where do I find this information? is the psychiatrist is a specialist and that we should be able to bill for the psychiatrist as a new patient visit? 

Please help.

Thank you


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## Evelyn Kim (Sep 27, 2018)

J5Murin said:


> I do internal auditing of E/M levels. I was initially asked to do this in order to educate the provider on how to improve documentation in order to better support the billed level of service in the future. The company is now asking me, pre-billing, to place an addendum on the provider's note stating the level of service that I find is supported as written. This is to be done when the provider refuses to change the level of service. I know that the provider is legally responsible for the DX code, but is there an ethical or legal conflict with changing the selected level of service? Is there a conflict with what I am being asked to do? Jacki M., MA CPC-A



From a payer's point of view, this would not be acceptable documentation for changing the level of service.  In fact it would raise red flags and could trigger an SIU investigation of the provider which could lead to refunds/recoupments and other sanctions.  

Addendums can be used by someone other than the provider as long as it does not affect the claim/level billed, these are usually in the form of phone calls related to the visit.  This is not the proper place to make notations regarding the billing.


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## BDunham7 (Oct 1, 2018)

In our office the E/M level and DXs are entered by the provider at the time of service, as part of the medical record. Not ideal, but that's how it's set up. The providers are willing to respect coder recommendations for E/M levels and DX codes based on the documentation. Where is the proper place to make any corrections? Is it acceptable to bill a different level than is indicated in the medical record (both higher and lower levels)? What record-keeping of the reason for the change is required? The logic in our office is that if the medical record is amended with the correct codes, then the provider must approve the changes before re-signing the note. We are a small office, so there is no compliance person to ask.


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