Question E&M level decision making?

kat22875

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Westlake, LA
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E&M level decision making?

I believe it is the Provider's responsibility to choose the level of E&M services he/she provided. Then it is the Coder who should review. We have some Providers that are saying it is the Coders who should choose the level. I am looking for supporting documentation to prove my point. I want to make sure we are in compliance.
:confused: Please help!!!!
 

carlystur

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Isn't the point of being a coder to be the one to choose the code itself? It might just be up to the practice manager to determine who s/he wants to actually code the level for E&M. In my case, the doctors are letting the coders choose the level for when they do procedures in the hospitals they use and when they use our clinic for follow up exams they'll most often do their own coding. Our practice manager wants our doctors to learn how to code their own examinations anyway, so I guess we'll see.
 

mandymmathison

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Columbus, MI
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Our practice the doctors chose the levels and the coders scrub the claim for modifiers, remove any unaddressed diagnosis and insurance rules. We have a chart auditor that makes sure the physicians are educated in choosing the right level based on documentation. At the end of the day they're responsible for anything submitted in their name and should review it prior to claim submission. You're responsible for coding to the highest level of specificity and flagging any fraud, waste or abuse.

Here's what CMS says about it. May be someone can share more from the OIG since I am still learning compliance.

When billing for a patient’s visit, select codes that best represent the services furnished during the visit. A billing specialist or alternate source may review the provider’s documented services before submitting the claim to a payer. These reviewers help select codes that best reflect the provider’s furnished services. However, the provider must ensure that the submitted claim accurately reflects the services provided. The provider must also ensure that medical record documentation supports the level of service reported to a payer. You should not use the volume of documentation to determine which specific level of service to bill.
Services must meet specific medical necessity requirements in the statute, regulations, and manuals and specific medical necessity criteria defined by National Coverage Determinations and Local Coverage Determinations (if any exist for the service reported on the claim). For every service billed, you must indicate the specific sign, symptom, or patient complaint that makes the service reasonable and necessary.

 
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