• If this is your first visit, be sure to check out the FAQ & read the forum rules. To view all forums, post or create a new thread, you must be an AAPC Member. If you are a member and have already registered for member area and forum access, you can log in by clicking here. If you've forgotten the password it can be reset on our sign in section by entering your registered Email Address or Username here. To start viewing messages, select the forum that you want to visit from the selection below..

Wiki Downcoding due to Medical Necessity?

Create Wiki
G

gkarow

New
Messages
3
Location
Mendota Heights, MN
Best answers
0
What do you do in the instance where the documentation clearly supports, say a 99214, but the presenting problem (say a sore throat) doesn't? Is it legal to code a 99213 even though that wasn't what was documented?
 
I have seen this as an issue especially with EMR use. Remember the MDM should drive the code. I have downcoded a provider for medical necessity to avoid the appearance of abuse.

Laura Cain, RN, CPC
 
Agree with gkarow. MDM is the driving force for the E/M level. It's great you have a provider that is such a good documentor (not sure thats even a word, lol). I have some that make it tough to even get a level.
 
Presenting problem vs diagnosis

The problem I have with this is that the "presenting problem" or chief complaint, is NOT the diagnosis. It's what the patient says is wrong.

I may say I have a sore throat, but only the physician's exam and expertise will diagnosis this as tonsilitis or strep throat or thrush or "just a cold."

I do not downcode based on the presenting problem. I will downcode if the MDM doesn't meet the level of service that the exam & history show.

It's a subtle but important difference.

Hope that helps.

F Tessa Bartels, CPC, CEMC
 
You must log in or register to reply here.
Top