Wiki Looking for advice using the MCR 1500 form & E/M coding

[Carroll1220]

Good evening!

I am a new coder starting a part time job at a local doctor's office and they only see 2-3 patients/day. They use the new Medicare 1500 form that was just released and I will be filling it out using a type writer.

My question to you is when I asked them if they do E/M coding, they did not seem aware of what that was. If I remember correctly from my coding class, physician offices usually use E/M. So in this case, I was told that perhaps the doctor assigns the level for E/M and all they want me to do is code the diagnosis code. I just want to make sure I do everything as correctly as possible in this new job and wanted to see if anyone has ever encountered this or has any suggestions?

Thank you so much, in advance, for your assistance and advice. It is quite appreciated!

Noelle, CPC-A

 

[Pam Warren]

Did I read this right? A typewriter?

You should definitely ask them what your responsibilities are. Along with the fact that you're typing on a CMS 1500, I'm guessing that this group has no idea of the skills you possess, and how you can help them.

Do they want someone to just fill out claim forms, using their fee ticket to do that? Or do they want a coder/auditor who can help them with their documentation improvement?

The 'best' way to code is to have a coder review the documentation, abstract the dignosis and level of service, and then bill the claim out according to the payer guidelines.

 

[MarcusM]

A typewriter, and probably a yellow ledger card system? with balances carried forward from 26 years ago? Been there and done that...good luck....

 

[scadykat]

Hey Noelle,
Does this physician office use an EHR or paper charts? How is the documentation done?

 

[seanny]

I think Medicare accepts paper claims only in special circumstances:

(PAGE 9)

https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/downloads/MedicareClaimSubmissionGuidelines-ICN906764.pdf

 

[erjones147]

Make sure the provider writes the dx out in plain language or puts the ICD-9 code somewhere on whatever internal chart you guys use, and then the put the codes into field 21.

Then you can choose the correct E/M code from their documentation and CPT guidelines and put that into 24D

Don't forget your modifiers and diagnosis pointers

Good luck!!