Wiki patient challenges EM coding

[ollielooya]

Patient is asking why the doctor coded a higher level visit (established patient-level 4) than a prior level 3 visit. She says that doctor performed the same type of service and was wondering why she was being charged more. Doctor wants the billing office to handle her question, and basically give a mini-lesson on EM coding and all that goes into it to justify the higher level.
Can some of you comment/furnish an example of how you may respond to the patient? I've seen this thread before either here or on some of the other listservs I frequent, but can't pull up the threads. And I'm sure some of you have had to deal with the exact same scenarios.

---Suzanne E. Byrum CPC

 

[btadlock1]

Patient is asking why the doctor coded a higher level visit (established patient-level 4) than a prior level 3 visit. She says that doctor performed the same type of service and was wondering why she was being charged more. Doctor wants the billing office to handle her question, and basically give a mini-lesson on EM coding and all that goes into it to justify the higher level.
Can some of you comment/furnish an example of how you may respond to the patient? I've seen this thread before either here or on some of the other listservs I frequent, but can't pull up the threads. And I'm sure some of you have had to deal with the exact same scenarios.

---Suzanne E. Byrum CPC

You could try referencing the clinical examples in Apopendix C, if one's close enough to the scenario for comparison, or show her how the visit lines up with this:
http://trailblazerhealth.com/Publications/Job Aid/coding pocket reference.pdf

I think that once she sees it's not an arbitrary selection process, she might stop arguing... Good luck!

 

[Mojo]

Just a thought: if you use the MDM to drive the level, perhaps the previous visit also had moderate MDM (confirming the patient's assessment of the same type of service provided) but the provider's documentation of the hx or exam was deficient, resulting in a lower level.

 

[mitchellde]

I think a patient has every right to understand how the visit level for their visit was determined. Not examples but specifically their visit. I would sit with them and review the visit documentation and explain exactly how the levels for the two different visits was determined. Because if you cannot explain it to the patient using the guidelines then it should not have been billed that way to the provider. A patient is allowed to have access to the documentation in their chart if they request it. I always request to see mine and I always argue the selection of the level of service, most of the time the office nor the physician can justify the level of service submitted using the guidelines and good logic, which results in a corrected claim.