I am a newly certified CPC and my methods are being attacked where I work regarding e/m services. Maybe I need some more info/training on this but please tell me if I am doing this correctly. I work on the payor end, and am being told, by someone not certified, that I am doing this incorrectly.
The provider is documenting in their notes that a complete ROS is being done, in addition to an extended HPI and pertinent PFSH, The exam is expanded problem focused and the MDM shows 3 dx codes, no testing additinal data, but on the table of risk the patient is on narcotic pain meds, which is moderate risk if you use the 2 of 3 method. Since is it an established patient and they have met 2 of 3 I have stated that this is a 99214.
The person that is attacking my coding is stating that the ROS is being done too much, how do we know that it was done, it isn't listed in the exam. He isn't really having that done on every visit.
Now, my understanding is that I am to code the notes for that date of service, not look at every visit that the patient has had and "decide" that it wasn't really done and reduce the level of visit, but maybe I am wrong.
Please help and tell me if I am doing this right
The provider is documenting in their notes that a complete ROS is being done, in addition to an extended HPI and pertinent PFSH, The exam is expanded problem focused and the MDM shows 3 dx codes, no testing additinal data, but on the table of risk the patient is on narcotic pain meds, which is moderate risk if you use the 2 of 3 method. Since is it an established patient and they have met 2 of 3 I have stated that this is a 99214.
The person that is attacking my coding is stating that the ROS is being done too much, how do we know that it was done, it isn't listed in the exam. He isn't really having that done on every visit.
Now, my understanding is that I am to code the notes for that date of service, not look at every visit that the patient has had and "decide" that it wasn't really done and reduce the level of visit, but maybe I am wrong.
Please help and tell me if I am doing this right