Wiki G0101 vs E/M for Coverage

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centralizedcoding

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What are the rules for changing an already billed Medicare YCU_G0101 over to an E/M visit purely for getting it paid?

This has been an ongoing issue w/ our practice for as long as I can remember and I have avoided it like the plague bc generally most of the time the either signed an ABN or there was not one on file therefore I would have it written off. I just don't like the way it sounds when asked to change G0101 over to a problem visit simply just to get it paid nor am I comfortable w/ doing so but these pts are really tough to deal with and relentless in their attempts to get their YCU covered which takes a multitude of my time when it comes to these. If it were an accident pt was given a YCU and addressed problem as well and provider not paying attention bills as YCU then I'm ok with asking him to amend his note to strike thru the YCU as his mistake. Thanks for any advice given!
 
I agree with you.
The "rules" are that an encounter must be coded and reported based on the documentation.

If the documentation does not support an E/M, I wouldn't be comfortable coding an E/M.

Having said that, I suppose it would be possible for your practice to document a policy/protocol for these situations.
I would also, suggest that if they are so concerned about getting paid, they really should make more of an effort to get an ABN signed by the patient.
 
I don't like to use the "F" word, but CMS defines fraud as “the intentional deception or misrepresentation that the individual knows to be false or does not believe to be true,” and that is made “knowing that the deception could result in some unauthorized benefit to himself or herself or some other person."
This does not preclude correcting an error that was realized after a claim was submitted. The services should be coded accurately the first submission. If the service supplied was a breast and pelvic exam for screening purposes, it is simply incorrect to code it as a problem oriented E&M service.
I will note I believe many clinicians do not sufficiently document high risk in order to have the G0101 (and Q0091) covered annually (instead of every 2 years) by Medicare. Here are the requirements: https://www.cms.gov/Outreach-and-Ed...ownloads/Screening-papPelvic-Examinations.pdf

If your practice is doing insurance eligibility checks, this is a fantastic time to look into whether or not a scheduled Medicare patient is currently eligible for G0101. ABNs should be given to any patient showing as not eligible for G0101. While an ABN is not required to bill a patient for a service excluded from Medicare coverage, it is definitely a good customer service policy to inform the patient the services will not be covered before providing them.

If I were employed somewhere regularly asking me to submit incorrect coding just to receive payment, I would start by first explaining to the person asking why this is such a concern. I imagine this is an independent smaller practice without a compliance department, but that would be another avenue to pursue if available. I would explain I want the clinicians to be paid for all the work they do, but intentionally submitting incorrect claims is not the proper way to do it. I would keep explaining until someone listened, or I got tired of hitting a brick wall and decide to seek employment elsewhere. I hope someone listens.
 
Thank yall so much for your input on this I greatly appreciate it! I 100% agree with everything yall have said. We are a multispecialty practice but I only code for the OBGYN Department but it's really tough trying to enforce any kind of rules/regulations about things because I have so much volume but am trying to figure out how to streamline some things one by one. I am confident in what I am doing especially in my specialty as I've been doing it for 6 years but sometimes when you cant count on your other coding partner for reassurance and you continuously get this question you sometimes begin to doubt yourself.
 
Great guidance here. I'd just add that switching a preventive service (no copay) to a non-preventive (copay) is going to upset your patients and CMS/HHS OIG are very sensitive to anything that looks like an attempt to overcharge Medicare patients. Be careful too of waiving copayments and using the correct modifier when you issue an ABN.
 
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