Wiki Providers Approving Office E/M Level Changes by Coders?

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carlystur

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Our Revenue Cycle Manager, whom myself and another coder/biller work relatively closely with, has requested that we ask our providers for approval whenever we change an E/M level for one of their patient encounters. Our new coder/biller and I were talking about this request and she told me that she's never had to do that in the entirety of her healthcare career. She thinks it's pretty ridiculous and she's been doing it for about 25 years now!

I was wondering whether or not anyone else had managers who asked their coders to request approval for office e/m level changes from the proper providers.
 
carlystur said:
Our Revenue Cycle Manager, whom myself and another coder/biller work relatively closely with, has requested that we ask our providers for approval whenever we change an E/M level for one of their patient encounters. Our new coder/biller and I were talking about this request and she told me that she's never had to do that in the entirety of her healthcare career. She thinks it's pretty ridiculous and she's been doing it for about 25 years now!

I was wondering whether or not anyone else had managers who asked their coders to request approval for office e/m level changes from the proper providers.
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I'm sure others will be able to give you more detailed info, but I will address this from a "practical" viewpoint. In all my years working in clinics I have only known one doctor who took the time to understand E/M coding. All other doctors choose their codes "by feel"...their words, not mine. I don't think that physicians should be in the dark either. While I don't expect them to become CPC's, I think physicians need to understand enough about E/M coding to understand why changes are made. And it's very valuable for coders to work with doctors because we are not doctors. They see things that we don't. In my opinion, your coders and providers should work closely enough that both sides have input especially when the E/M level is "on the fence". My providers were grateful that I included them in the E/M coding process and they learned to respect my opinion.
 
carlystur said:
Our Revenue Cycle Manager, whom myself and another coder/biller work relatively closely with, has requested that we ask our providers for approval whenever we change an E/M level for one of their patient encounters. Our new coder/biller and I were talking about this request and she told me that she's never had to do that in the entirety of her healthcare career. She thinks it's pretty ridiculous and she's been doing it for about 25 years now!

I was wondering whether or not anyone else had managers who asked their coders to request approval for office e/m level changes from the proper providers.
Click to expand...

I think it is unreasonable to ask them for "approval" - what if they refuse? You're the trained coder, and you'd be at risk of compliance issues if you were expected to knowingly bill out an incorrect level.

However, it is reasonable to educate the provider on why levels need to be changed. Especially if there are documentation deficiencies that caused the need for changing the level.

Collaboration and education are fine. Straight up having to ask for approval wouldn't sit right with me.
 
In addition to the great answers above I'd add that this policy seems ripe for creating overpayments.

Even providers who don't know how to code understand that changing their codes means changing their payments. If they think they have the final say in how much they get paid they're going to say no to any reductions. But if they get paid for an upcoded claim that's an overpayment that will have to be returned within 60 days. In a worst case scenario this will escalate into accusations of violating the false claims act.

I don't think the doctors would be thrilled about that either.
 
That's a tough fence to be on. I have been in this industry for a minute myself. A question to ask yourself, does there need to be a written policy in place? This way a discussion can happen between coder and physician as to when an approval would be requested. I am sure the physician has no problem approving an up code. It is usually when the code is lowered the questions arise. Sometimes that provides a bit of education to the provider(s). It maybe helpful for them for future patient visits.
 
carlystur said:
Our Revenue Cycle Manager, whom myself and another coder/biller work relatively closely with, has requested that we ask our providers for approval whenever we change an E/M level for one of their patient encounters. Our new coder/biller and I were talking about this request and she told me that she's never had to do that in the entirety of her healthcare career. She thinks it's pretty ridiculous and she's been doing it for about 25 years now!

I was wondering whether or not anyone else had managers who asked their coders to request approval for office e/m level changes from the proper providers.
Click to expand...
we had a documented policy at my old practice, that stated, coders may change the level of service for a visit, BUT if there was a 2 level difference between what the provider submitted and what the coder came up with, we would have to discuss it with the provider. the policy, also, stated that if a provider submitted a 99215 and the coder did not agree, we would discuss with the provider.

I would imagine that most providers would get annoyed if they are constantly being asked to approve LOS changes.
 
I agree with everyone saying that it could be a way to educate our providers. I had considered that as a potential reason why my manager has requested this and have now asked said manager if that is the reason why we have been requested to ask for approval every time we want to change an E/M level on a visit. At this time, I am still waiting on her response. Will update when I hear back.
 
What I keep asking myself is what is the policy if (when) the doctor doesn't approve of the change? :LOL:
 
According to my manager, it is supposed to go out with the code originally chosen by the provider. One problem is that our providers have a bad habit of always choosing level 4s for new patient visits and level 3s for established patient visits - regardless of how much they did for that particular visit. I had gotten used to changing the level of their visits without them seeming to care. Perhaps they weren't paying attention to the fact that I had changed their levels based on the 2021 Guidelines. I believe this is partially based on one very bad day I had after discovering that they trust our medical director's old coder who is now considered a consultant for coding and, in order to keep my job, I followed that to the T as well as I could and therefore everything looked like a level 2 to me, according to her standards. The problem with the coding consultant is the way she is telling our new coder and myself to code our providers' visits is wrong! Sort of a combination of the pre-2021 and post-2021 guidelines where the second page of a standard E/M Audit sheet gets used so we can "take everything the provider has done into consideration". So, that includes stuff like "Established Problem Worsening", "New Problem Additional Workup Planned", "Medicine Section Ordered and/or Reviewed", etc.

I just got called into a meeting with my manager and was told that I'm soon going to be audited by our coding consultant and that's not a good thing for me because there were some legitimate level 2s that our coding consultant would consider as level 3s because of the amount of documentation the providers include in their notes. 😫 Ugh! She knows what the 2021 guidelines are, but she's capitulating to the doctors! I'm seriously getting my resume ready in order to find another coding job this weekend! I am not willing to risk my certification on this! 😤
 
I was so naive to think that I wouldn't have the same issue as I've seen so many other coders on here have where their providers won't trust them and trust other people who use the wrong guidelines, instead. I don't have a whole year's experience in coding for an office yet, unfortunately. That doesn't happen until October 1st, but hopefully another place will still take a chance on me. I'm thinking it's very possible that I will be fired relatively soon for not following directions since I wasn't following the standards of this previous coder whom my providers trust above anybody else.
 
carlystur said:
I was so naive to think that I wouldn't have the same issue as I've seen so many other coders on here have where their providers won't trust them and trust other people who use the wrong guidelines, instead. I don't have a whole year's experience in coding for an office yet, unfortunately. That doesn't happen until October 1st, but hopefully another place will still take a chance on me. I'm thinking it's very possible that I will be fired relatively soon for not following directions since I wasn't following the standards of this previous coder whom my providers trust above anybody else.
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Hi everyone,
I hear your frustration. Prior to my current job, I worked with a retina specialist and this dr would appreciate, implement and accept education on coding. This dr would allow me to train not just the billing staff but also the medical assistance. And as a collective group we would work to document so that the coding and billing would be justified. That staff was so good that they would come and point out something the dr failed to document when the dr ordered exams. Anyone one of us would be able to go to the dr and say “ you ordered this but the dx you provided will not cover the reason for the exam”. I really miss that team.
Currently I’ve been pulling my hair and I still can not create what I had. The billing department is great. They understand. But the clinical part of the office always opposes guidelines and even after I talk to my new dr and show him the guidelines, he’ll tell me “they are wrong”. You guys should of seen my face. I was left speechless. I don’t think think there is an emoji for it. Lol.
I have been documenting discrepancies but ultimately, I know I will be at fault as well.
What should we do in situations like this?

So I know how you feel. You have the answer in your hands and someone comes and says “that’s wrong”.
 
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