Wiki Need advice regarding E&M upcode

[steincamp]

I am in need of E&M coding advice and I would really appreciate input on this scenario:

This is regarding a routine E&M internal physician audit:

MD bills Initial Inpatient Admission – 99222

Leveled at 99221 under 97 guidelines
Leveled at 99223 under 95 guidelines

Question: Would you advise the MD to bill billed 99223 versus his selected code of 99222?

I, personally, would advise the MD to bill the initial E&M code selected of 99222. I would not advise the MD upcode to 99223, especially since case leveled at 99221 under 97. Other coders in our office think 99223 is appropriate. Will you please weight in.

(I am aware that before downcoding an E&M that you are required to audit by both 95 and 97. However, in this scenario - the physician isn't going to be downcoded to the 99221 that leveled under 97 because he/she met (and exceeded) billed code of 99222 under 95. I just don't think we should proactively encourage MD to change from 99222 to 99223 unless 99223 was met under both 95 and 97.

Input would be appreciated. Thank you-

 

[lphillips]

The provider only needs to meet the requirements for either '95 or '97 guidelines, they do not have to meet both. If provider documentation supports a higher level of service then what "they selected", it is not a bad or wrong thing to correct it appropriately. Under coding is just as bad as Over coding.

 

[Dorthi]

97 guidelines

According to my notes for the CPMA course I am taking he can go with the 97 guidelines.

1. Provider can choose to use either guidelines per visit as long as they are not intermixed.
2.When audited by CMS they state they will refer to both 95 and 97 guidelines and more or less says the one that gives the physician the better end is the one that will be used.

So the point of this would be to encourage him to meet the 97 guidelines if that is where the criteria lies.

Right?