Wiki E&M billing every OV

[PBS123]

I bill for Acupuncturists in California and my provider is adamant that I bill an E&M code with every visit specifically with Aetna. Does anyone have direct experience billing with Aetna and their philosophy on billing an E&M every visit? Does it make a difference if we're in or out of network?

I have also heard that insurance companies are now using data mining and looking for coding patterns and auditing physicians. My provider claims with the above situation that practitioners have been billing like this for years. But, I'd like to explain to her that insurance companies are starting to take action and there's a good change she could get audited.

I would love to hear what other people know about these two topics.

Thank you,
Annie

 

[jfree104]

Dr needs to ask herself if the patients condition required a separately identifiable Evaluation and Management from the procedure. example: Did the patient fall and hit his/her head requiring stitches and require a full workup to rule out a concussion? CMS guidelines make it clear that the E/M must be separate from the procedure.

 

[1formissy]

I agree with jfree104. You MUST be extremely careful when reporting an E/M for any visit. The documentation MUST support a signficiantly separate and identifiable service from the acupuncture procedure. As an auditor myself, and a coder, I do data mining and you are correct. Insurance payers are watching for these types of patterns. If your provider is using an EMR, for example, make sure the information provided in the medical record is not only pertinent to the reason the patient is being seen, but must support medical necessity. Remember, if you are billing for services you believe your provider may not be entitied to, the OIG clearly states that you are just as responsible as the provider. I strongly suggest you review the E/M documentation guidelines on CMS website, and look at the OIG website. It gives you a very clear understanding of what Medicare requires.