Wiki E/M not billable?

Create Wiki
C

cheryldudley8

Guest
Messages
14
Best answers
0
Good Morning fellow Coders,

We had an auditing firm disagree with some of our E/M's with their explanation as the visit was not "billable". The reason they felt these visits were not billable had to do with the HPI not being documented by the provider. I know this a DG, so in these cases, the History component i guess was considered incomplete/void ( by the auditors) and deemed the entire service as not billable. My question with this is, for the established patients, only two criteria are required so if there is either detailed/comprehensive PE and a MDM of low/moderate etc ( do not know the specific case scenario of what level pe/mdm etc) . why couldn't these established visits be acceptable/billable? I've been researching and researching and can't find anything in writing to state that if a criteria is incomplete/void/doesn't even meet lowest level, (especially history due to documentation errors etc) the entire visit isn't billable. I can of course see this to be true for new patients,(need three of three) but i was curious if anyone either has seen this documented somewhere etc or had any advise on this type of situation? Any help would be greatly appreciated as we are planning on giving feedback and would like documented proof, if this scenario isn't truely billable?
 
E/M not billable

Hello,

Medicare states only two out of the three components (history, exam, & MDM) are required to meet the level of service billed. It's a good idea to make sure that one of the two is the medical decision making. I agree with you. I would go back to the auditors and ask where they are getting their information.
 
Although Medicare says that only 2 out of the 3 key component levels must be met, if the medical necessity for the visit is not established, it will be denied for "not medically necessary." This is often established in the history. Remember, each record should be able to stand on its own.

That may be what the auditor is looking for. They should be able to explain their reasoning further.

Holly Pettigrew, CPC, CPC-H
Physician Coding Auditor
 
Our contractor, NGS requires that three key components be documented for all visits; not just in order to meet the level.

Missing history components could very easily cause the note to not meet medical necessity. How can an exam/decision be concluded and supported if the history is not documented? With medical necessity being the overarching criteria, the omission of any of the three key components is cause for concern. Here's what our contractor communicated to us.

In the JK Part B Evaluation and Management Prepayment Review Findings for June, July and August, 2014, NGS indicated that claims may be denied for lack of an exam and/or history missing.

 
Thanks everyone for their responses, it has been very helpful :)

Pam, is there any documents/articles/guidelines you could either guide me to or reference in regards to NGS rulings on this or any documentation guidelines? We share the same MAC, NGS as we are both in NH, and would love to be able to read more on what the specifics are for NGS as I have not been able to find much?

Thanks again
 
You must log in or register to reply here.
Top