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BS&SC

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When in Cerner, there can be several of our providers doing labor progress notes, or regular visit notes, throughout the day. When billing for MCO, how do I know which note to choose to bill from?

A separate question: If the note I choose doesn't have an exam documented (patient denied exam) and it is one of the three required, do I just bill nothing, or can I bill the lowest?
 
BS&SC said:
When in Cerner, there can be several of our providers doing labor progress notes, or regular visit notes, throughout the day. When billing for MCO, how do I know which note to choose to bill from?

A separate question: If the note I choose doesn't have an exam documented (patient denied exam) and it is one of the three required, do I just bill nothing, or can I bill the lowest?
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What you are asking is not entirely clear to me. Is the patient being seen in the hospital for a labor check or is she in active labor and being seen by whoever is on call? Is this a term pregnancy and so the work is part of global care or it is something else? In general if one entity is billing you add up all the documentation done that day to pick the final level of service and I guess you could assign it to the last person who saw the patient on the date of service- each individual provider in that billing entity will not be paid for their E/M services separately. Again, are you billing a code that requires an exam or is time allowed as an alternative? For instance, all the inpatient codes include bedside/floor time as a selection criteria instead of the the HX, PE, and MDM. If it is an outpatient billing instead you now select the codes by MDM or time only. If observation is being billed, those codes also have a time option.
 
This is helpful. Thank you. To clarify, it is billing for a Medicaid. The woman was admitted three days before delivery and Cervidil was given. So I know I can bill for the Cervidil, but the one provider from our group that saw her that first day did a very brief note. I just kind of scratched my head and wondered if I can bill the lowest level, or if it is best to not bill anything at all for that inpatient E&M since 3/3 is needed.

You mentioned that every note from our providers in a day can be pulled from for subsequent care codes. . .is there an example of how to do this? I wish I had another coder in the office who uses Cerner, but I am the only one, and though I work in an office, I am an 1 1/2 away from the hospital and our providers.
 
BS&SC said:
This is helpful. Thank you. To clarify, it is billing for a Medicaid. The woman was admitted three days before delivery and Cervidil was given. So I know I can bill for the Cervidil, but the one provider from our group that saw her that first day did a very brief note. I just kind of scratched my head and wondered if I can bill the lowest level, or if it is best to not bill anything at all for that inpatient E&M since 3/3 is needed.

You mentioned that every note from our providers in a day can be pulled from for subsequent care codes. . .is there an example of how to do this? I wish I had another coder in the office who uses Cerner, but I am the only one, and though I work in an office, I am an 1 1/2 away from the hospital and our providers.
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If the MD who put in the cervidil is the one who wrote the brief note, I would not bill an E/M as it appears the "visit" was to do a procedure, not an evaluation of the patient for a complication. As to how to combine the notes, other than viewing all the documentation and then determining what the real level would be, and documenting who reviewed it and made the code selection. I am sorry, but I am not familiar with Cerner.
 
It sounds like there is some missing documentation somewhere which is concerning. Does your hospital use Powerchart with Cerner, if so; check the "order tasks" to see if it shows who ordered the Cervidil and query the provider. I am on the outpatient side of things so I don't know how much it differs from an inpatient/outpatient set-up. If you don't see it then I would get with your supervisor to see if it's missing documentation or something else. Also, I know you are in PA but AL Medicaid only allows 1 provider to bill per group per day but I don't know right off hand about billing all under the admitting physician. Hope this helps.
 
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