Wiki E/M visit level

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MonicaDay

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Local Chapter Officer
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Oak Harbor, WA
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Hello, I work in an orthopedic office with 3 surgeons. One of our doctors has been questioning his visit level. He has a solid 4 by the 1997 guidelines, but he wants to upgrade to a level 5 as he used an interpreter. The time is not noted. We have advised the physician that we need documentation that the guidelines would actually move the level to a 5 just from the interpreter. Please help. We have looked on the internet, coding books, other offices. No straight answers to this point. Thank you. Monica Day
 
You cannot change the level just because he used an interpreter. He is still getting the information from the patient so it doesn't increase the complexity of his decision making. Under federal law you cannot bill either the patient or the insurance company for the use of an interpreter, it's considered part of the cost of doing business (a very expensive cost unless you have a friend or family member interpreting).
 
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