Wiki exam question

[happytobecoding]

For the exam how would you answer this question:

If the coder/auditor dosesn't have enough information to code a service, should she/he :

Ask the physician for clarity

go back to the documentation

go with what is there and code to a low level

Thanks, any information you can give me regarding this would be great !!

 

[dwaldman]

I think it depends on the documentation and the kind of visit. We have a physician who goes to Inpatient Rehab facility and does a hand written initial consultation note. From that note, it does not meet the criteria to bill 99221 so we bill 99499 when billing Medicare, which they process. I think you would want to talk to the physician or compare to a superbill which would have the level he believes it is to make sure he is aware of the requirements for the certain E/M service he is providing.

 

[happytobecoding]

thanks so much I thought this was the answer but just wanted to check !!