• If this is your first visit, be sure to check out the FAQ & read the forum rules. To view all forums, post or create a new thread, you must be an AAPC Member. If you are a member and have already registered for member area and forum access, you can log in by clicking here. If you've forgotten the password it can be reset on our sign in section by entering your registered Email Address or Username here. To start viewing messages, select the forum that you want to visit from the selection below..

Wiki How would this be formatted?

Create Wiki
E

elljay68

Networker
Local Chapter Officer
Messages
59
Location
Tacoma, WA
Best answers
0
I'm currently a medical transcriptionist and will be completing the coding course in a few weeks. I have a dictation from one of our doctors and need help with formatting:
Dr. X always starts his dictations with a subtitle describing the type of service (he's the only one I know of who does this); for instance, I am working on a report right now where he dictates:

"This is a level 4, 99214 check back with a number 25 E/M modifier and a number 51 E/M modifier on patient xxx..."

Would this translate to
LEVEL 4, 99214-25-51 CHECK BACK

I searched my textbook and flipped through the CPT and the workbook and couldn't find info on coding multiple modifiers so I am not sure.
 
I would have several questions..........

1) mod -51 is not appropriate with an E&M code

2) is this a note to the coder on how he wants this encounter coded? Meaning instead of using a superbill he is noting his coding as a pre-statement to his visit documentation. Does the coder see this pre-statement?

3) I really wonder how an auditor would look at this. Would it be viewed he is dictating the note to meet his stated E&M level rather than the code being assigned based on what was done (medical necessity)
 
Last edited:
Well, now that you mention it, I remember that -51 would be inappropriate!

He nearly always starts his dictations this way, and I have always transcribed this as a subtitle in the report, but I would spell out the word modifier...and not append the modifier to the E/M (out of ignorance of coding conventions)...this is the first time I can recall that he has listed a second modifier.

Thanks for your helpful feedback!! I'll put this in QA.
 
I have just never seen a physician start his note with that kind of coding statement. When the note is sent back to the Physician who made the referral/consult request, dose this coding statement remain in the note? I think you're right to have QA look at this. I wonder if other physicians in the practice are aware that he is doing this
 
I have to say, too, that I'm quite sure this goes through a coder before it's reported for billing.
 
I don't know...I did just get confirmation that a coder looks at it before billing takes place, and that person probably just rolls her eyes. He's trying to be helpful, but I'm learning a little knowledge can be dangerous!!!!
 
You must log in or register to reply here.
Top