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[charonate]

I have a note that I don't feel comfortable billing for what the Dr. is billing..

99204 and G0438 (Dr. billing)

Beginning of note...

Reason for visit..
1.hypertension. never been on meds.
2. neuropathy LE . x3yrs on gabapentin and helps, has poor balance and has fallen in past.
3. dental implants. is on nystatin S&S.
4. breast ca. lt side. S/P mastectomy stage 2. had implant. sees dr. ..
5. memory loss. had a ministroke 2009. not on aspirin cuz side effects.
6. colon polyps. had several colonoscopies.

chronic problems.
neuropathy, benign hypertension, esophageal reflux, memory loss, breast ca.

PHSF..
family. copd and premature cad
social. primary language is english
marital, tobacco use, allergies.

ROS.
resp, derm, neuro, musc.

physical.
constitutional, eyes, ears, nose, mouth adn throat, neck and thyroid, lymphatic, breast, resp, cardio, abdomen, rectum, extremities, neurological psych.

assessment.

Routine general medical eva.
neuropathy- on gabapentin
esophageal reflux -cont nexium
breast ca-order mammo
hx of cva- ordered mri
memory loss- ordered carotid doppler
hypertension-very high.

I will just bill a level 3 new patient.. any suggestion please..

 

[kellyross]

audit

I would recommend that you do an actual e/m audit of the note and then "suggest" to the physician that the notes support a level "whatever you come up with"... then support that with your audit.

However, the fact that he's billing the additional code with it does not seem surprising to me - but you may need a modifier on your E/M.

Those G codes are paid at "carrier discretion". Is this a Medicare patient? The note needs to also reflect that a "personalized prevention plan of service (PPS) was provided for the patient.

Whatever you do - DO NOT just change the code before consulting with the physician. It is the physician who is assigning codes - however, the coder should be assisting in making the physician aware of the documentation.

I hope this makes sense and is helpful. ?????

 

[charonate]

I would recommend that you do an actual e/m audit of the note and then "suggest" to the physician that the notes support a level "whatever you come up with"... then support that with your audit.

However, the fact that he's billing the additional code with it does not seem surprising to me - but you may need a modifier on your E/M.

Those G codes are paid at "carrier discretion". Is this a Medicare patient? The note needs to also reflect that a "personalized prevention plan of service (PPS) was provided for the patient.

Whatever you do - DO NOT just change the code before consulting with the physician. It is the physician who is assigning codes - however, the coder should be assisting in making the physician aware of the documentation.

I hope this makes sense and is helpful. ?????

but based on the info do you think it supports both charges?

Thank you,