Ophthalmology and Optometry Coding Alert

Question: One of our ophthalmologists allows his medical assistant to choose his E/M codes. The assistant is not a certified coder and always picks the highest E/M code possible. Is there anything in writing stating that only a certified coder or physician can choose the codes?

Answer: There are no written guidelines stating that a physician or certified coder must choose procedure codes. The physician can delegate that responsibility to another person, but needs to understand that doing so does not release him from liability related to the other person’s actions. The physician is ultimately responsible for services reported under his name and NPI, regardless of who selects the codes.

Suggestion: Print out some bell curves on appropriate E/M code levels to show the physician and his medical assistant. Discuss the possibility of increasing your chances of an audit because of all the high-level codes. Also provide education helping the medical assistant distinguish between the different code levels, so her choices will be more in line with the services provided.