Wiki E/M levels chosen by provider

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JWismer

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I'm fairly new to coding/billing, been doing it for just over a year now. My practice manager told me and our other coder/biller today that it is ILLEGAL for us to change the level of E/M circled by the doctor on the superbill. I was a little confused by this because I always thought it was the role of the coder to read the doctors notes and determine the level of the office visit.

She proceeded to tell us even though the note has no HPI, no physical exam, and no review of systems that because the doctor circled a 99204 on the superbill that we HAD to bill it out as that code. She also said that the doctor would be the one held liable for any audits. I recently became certified and my understanding was that if I knowingly upcode that I could lose my certification. I know I'm still new to the field but I thought this was considered insurance fraud, since it clearly doesn't meet the requirements for a new patient level 4 office visit.

Can anyone offer me some guidance as to what to do here, or how to handle this situation going forward? Im very confused now because I don't want to do anything illegal and I thought I was doing it correctly when I reviewed the doctors note for the office visit and adjusted his E/M level according to the requirements for each level of service. Thank you for any help with this matter.
 
I would not overcode under any circumstances. Can you query the doctor and ask him addend the note to reflect the missing elements? I do E/M coding and I am allowed to code according to what the note reflects. So if my doctor selects a 99205 ( which he does all the time) It is almost never that level...majority of them are 99203's. So I bill accordingly and he is fine with it. He is very supportive and does not want to risk an audit. And keep in mind if he is audited..you will be held accountable as well. Hope this helps
 
JWismer said:
I'm fairly new to coding/billing, been doing it for just over a year now. My practice manager told me and our other coder/biller today that it is ILLEGAL for us to change the level of E/M circled by the doctor on the superbill. I was a little confused by this because I always thought it was the role of the coder to read the doctors notes and determine the level of the office visit.

She proceeded to tell us even though the note has no HPI, no physical exam, and no review of systems that because the doctor circled a 99204 on the superbill that we HAD to bill it out as that code. She also said that the doctor would be the one held liable for any audits. I recently became certified and my understanding was that if I knowingly upcode that I could lose my certification. I know I'm still new to the field but I thought this was considered insurance fraud, since it clearly doesn't meet the requirements for a new patient level 4 office visit.

Can anyone offer me some guidance as to what to do here, or how to handle this situation going forward? Im very confused now because I don't want to do anything illegal and I thought I was doing it correctly when I reviewed the doctors note for the office visit and adjusted his E/M level according to the requirements for each level of service. Thank you for any help with this matter.
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Hopefully someone will come along with some better advise but id also start looking for other jobs just to be safe. If they threaten you with firing if you don't so what she says you can only claim duress for a short period of time . How big is the organization. Is there a separate corporate compliance department you can go to or is this a small clinic?

I'd maybe casually bring it up with the physician, maybe he has no idea his practice manager is giving this completely inaccurate advice.
 
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E/M coding

Your Office Manager is incorrect.
It is NOT illegal to correct the physicians errors. Physician are NOT coders. That is why they hire us. It is our job to follow the rules and regulations! It is also our job to educate the providers the correct way to choose their codes. I have gone over the E/M cheat sheets with many physicians and they had no idea that they were "choosing" incorrectly. When I do "correct" their coding mistakes I always send them a note explaining WHY I have changed their code. Here is an example of one of the e-mail's I send:
"The notes justify a 992XX not a 992XX. There is no documentation of time so I have to gauge it by, HPI,
Exam and MDM only and I can only come up with a 992XX.
A 992XX would need a to be documented as __ minutes with more than 50% of that time face to face counseling the patient"
Believe it or not most physicians are very receptive to the constructive criticism and they improve their documentation as well.

Good Luck!
 
From a legal perspective the claim is an attestation statement, from the one that submits it, that information on this claim is an attestation that it supports the information in the medical recorded. You are to never put information on the claim that cannot be backed up with the documentation. The coder is considered to be equally liable for this information.
 
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Thanks everyone. We are a smaller urgent care/primary care office with 2 locations, and were just recently bought by a hospital as well. The providers are always willing to adjust their notes appropriately when there is missing information, but I just got confused by the practice manager telling us that it didn't matter what the note said, we had to use the doctors code. I've always changed the level of service the doctors chose, they always think they did the work of a level 5, however a lot of their documentation doesn't meet that level and we have always adjusted accordingly.

I just wanted to make sure I was correct in choosing the codes based on the documentation before I refused to do what my manager is telling me to do. I will be looking for better employment, really don't want to work for a place that encourages us to break the coding rules. I thought the coder was help liable for their work but she is trying to convince us that it would only be the doctor and I don't want any part of that nonsense.

Thank you for all the advice, this helps a lot.
 
JWismer said:
Thanks everyone. We are a smaller urgent care/primary care office with 2 locations, and were just recently bought by a hospital as well. The providers are always willing to adjust their notes appropriately when there is missing information, but I just got confused by the practice manager telling us that it didn't matter what the note said, we had to use the doctors code. I've always changed the level of service the doctors chose, they always think they did the work of a level 5, however a lot of their documentation doesn't meet that level and we have always adjusted accordingly.

I just wanted to make sure I was correct in choosing the codes based on the documentation before I refused to do what my manager is telling me to do. I will be looking for better employment, really don't want to work for a place that encourages us to break the coding rules. I thought the coder was help liable for their work but she is trying to convince us that it would only be the doctor and I don't want any part of that nonsense.

Thank you for all the advice, this helps a lot.
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you are welcome...and if you have to look for another job..dont worry..you are in HIGH DEMAND :D
 
If you cant get the office manager to budge you should probably let the compliance officer at the new owning hospital know to make them aware so they can do damage control when its still in the self reporting window.
 
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