Ob-Gyn Coding Alert

Question: I have been asked to get some additional professional input on the way audits are handled.

An audit is performed prior to the claim being filed to insurance and it is discovered that the doctor has marked a 99215 but upon audit the level only meets a 99214. The doctor has received one-on-one training, and it has been explained what constitutes a level 5. The doctor has a copy of the requirements.

Once it has been identified that it does not meet a 99215, is it acceptable for the doctor to make amendments to the note so that they claim can be filed as a 99215, or should it be considered as a training opportunity and the 99214 should be billed without the doctor going in and amending the note?

Also, is it acceptable for a physician to consistently reach a level 5 by utilizing the option under amount and complexity of data reviewed to review and summarize old records and/or discussion with other health care provider? For example, any time a patient is seen as a follow up to a hospital or ER encounter the doctor summarizes the report, then typically orders lab and x-ray and then meets a high level on number of diagnosis and management options. This can result in 10 level 5’s in the course of 3 days.

Kansas Subscriber

Answer: Absolutely not for question number one. He documented what he documented, and it is not appropriate for him to amend the note to reach the higher undocumented level of service. The purpose of the audit result is education, not recoding. In addition, any amendments to the note must clearly note when it was done, but more importantly, the physician would also have to document WHY he had to amend the note. The amendment needs to be for a medically justifiable reason (such as, reporting the incorrect medication or failing to document a test that was ordered).

As to the second question, reporting 10 level 5’s in 3 days may be highly suspicious to any payer and may result in an audit for medical need of this level of work. You will have to determine how to handle this based one a well thought-out protocol, and then in the end, the physician must be able to adequately defend his billing level via medical need to provide these highly complex services. There may in fact to a payer audit in your future.