Wiki Assigning OV levels

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koneal

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If progress notes are provided and it is your job to make sure that the HPI/ROS/Exam/MDM match what the provider has checked off and you find it to be lower or higher is it your responsibility to up code or down code it and then bill it, or do you send it back to the provider for review for he/she to change?

E/M newbee:D
 
Unless and until there is a big issue in documentation, it is your responsibility to correctly level the OV. It's always good though to check with your provider what are you changing and why. Some of them can be very outrageous :).
 
This will depend on your office policies/procedures

It will depend on your particular office policies/procedures. I worked for one practice where the physician had to be contacted (and agree) before we changed any code - up or down. In my current situation, I will level the code based on documentation and simply inform the physician of the change.

Check with your supervisor.

F Tessa Bartels, CPC, CEMC
 
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