Wiki difficult physician billing 99291 without documentation to justify

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lec121661

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Hello maybe someone can help me, one of my physicians billed a 99291, the patient was in ICU, after reading the progess notes no time was documented and it stated patient doing well, patient has atrial fibrilation, when i approached the physican he was very unprofessional, he threw the posted it at me and stated how can I not bill a critical care when I am the sole provider of the patient when i explained to him that the guidelines state that the patient does not constitute a 99291 just because he/she is in ICU, that a higher E/M code could possibly be used and that 99291 must show time. he refused to except what i had said. what would you do in a situation like this

any assistance would be appreciated

thank you
LaTanya Cross CCS-P, CPC
 
I just had the same scenario

Just because the doctor put down for a critical care code, doesn't mean he gets what he wants. You can stand firm and give him the correct code which is a inpatient code. I don't know which one specifically because what you said here, doesn't give me much to go on because you didn't mention what type of exam and MDM he documented, if any. I just had the same thing happen to me and a provider. Once I showed him what he could do, he went with the inpatient because the time wasn't documented and it was an EMR transmittal which wouldn't look that credible if he tried to change it to match a critical care code. And besides, he sounds like he doesn't understand what critical care stands for and the difference in ICU coding. You could teach him! Take the opportunity to empower a doctor to change his thinking!
 
critical care coding

thanks Kelly,

I have been trying to do that since I have been employed with this practice, but they have never had anyone review there documentation as such, or even educate them on the correct coding issues that they have, and also if you do not have anyone to back you up when you are teaching them, that is hard as well

thanks

LaTanya :)
 
What works well with my Physicians is to pull the CMS guidelines from the website and refer to it during my conversation with them. They might argue that you don't know what you're doing (talking about); but it's pretty hard to argue with the CMS guidelines- which are very specific about Critical Care.
 
lec121661 said:
Hello maybe someone can help me, one of my physicians billed a 99291, the patient was in ICU, after reading the progess notes no time was documented and it stated patient doing well, patient has atrial fibrilation, when i approached the physican he was very unprofessional, he threw the posted it at me and stated how can I not bill a critical care when I am the sole provider of the patient when i explained to him that the guidelines state that the patient does not constitute a 99291 just because he/she is in ICU, that a higher E/M code could possibly be used and that 99291 must show time. he refused to except what i had said. what would you do in a situation like this

any assistance would be appreciated

thank you
LaTanya Cross CCS-P, CPC
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Hi, that physicians reaction was absolutely unacceptable!! If he, in fact, threw something at you, even if it was only paper, you should report him to someone! Maybe the Chief of Staff, Compliance officer or even an HIM supervisor. That is ridiculous, and it is not right that you, or anyone else for that matter, be treated that way, especially when you are only trying to do your job to the best of your ability. There is such a thing as professionalism and common courtesy.

As for your defense, there are plenty of articles out there, including onthe CMS website, that dictates exactly what is necessary in order to charge for critical care and it ultimately falls on the coder to accept that responsibility, so don't code anything that you believe to be unethical. It's your tail on the line. You know what can happen if you bill certain codes that are not backed up with proper documentation!
And, I also do agree with the others, that a better outcome would be if you could educate him. Maybe, possibly work together in the future to create some sort of critical care checklist or guidelines, or something like that, that could be used by physicians there as a sort of guide to critical care coding, what counts and what does not, etc. The ACEP website has some great info on CC coding. The important thing is to stand up for yourself while protecting yourself. Education is power with physicians. They just see things very differently from us and sometimes the barriers between us are very hard to get through. Hang in there and keep trying:)
 
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