Wiki Provider Based Coding

[mllivers]

Can anyone give me some guidance on provider-based coding? I can't find anything up to date and it's very confusing to me.

 

[trarut]

That's a broad topic. Can you narrow it down to what specifically you need help with?

 

[mllivers]

That's a broad topic. Can you narrow it down to what specifically you need help with?

So, they are telling me that we send the level with every encounter, no matter the insurance. Then it says "we did medicare and Medicaids as provider based". Now I'm confused if all of them have levels what is the difference for medicare and medicaids?

 

[trarut]

I'm really sorry and don't mean to be obtuse but I don't know what you mean by "levels". Maybe someone else will know and be able to help.

 

[Orthocoderpgu]

Are you speaking of "E/M levels"?

 

[mllivers]

Are you speaking of "E/M levels"?

They are calling it a score level. The doctor completes a questionnaire and however many points there is a level it goes with.

 

[Orthocoderpgu]

They are calling it a score level. The doctor completes a questionnaire and however many points there is a level it goes with.

Sounds like the clinic is trying to come up with a way to determine E/M levels with the new 2021 guidelines. This is something that is specific to your clinic it seems.

 

[csperoni]

It sounds like you are asking for assistance with E/M coding for providers. Your employer is providing some type of tool. No one here would be able to assist you with questions regarding your employer's tool or requirements.
If you are looking with general information about coding E/M, there are many resources available. For inpatient, there has not been any changes and coding is based on either 1995 or 1997 guidelines evaluating history, exam and MDM (medical decision making). For outpatient, 2021 brought significant changes and is based on MDM only (with adjustments to MDM from 1995 & 1997). I have found the AMA guide most helpful https://www.ama-assn.org/system/files/2019-06/cpt-office-prolonged-svs-code-changes.pdf

 

[Birdie625]

Hi. I work for a hospital that is provider based and this is my 2c from when I was in the clinic billing department. For the insurances that processed pb claims, SSA medicare, our medicaid program pulled out of such, the clinic had to post a clinic charge (G0463) that went on UB claim and the provider would do the 992xx range that went on the 1500 claim. Search the net for G0463. AAPC posted an article on such. Management and finance dept worked together and created a grid for the nursing staff to input the clinic charge...info way over my head...and based on that grid from the work the nurses did, determined which 'level' of the clinic charge that got billed...what this did is split the fees between the hospital and provider. With provider based, the clinic was no longer an office (POS 11), but considered an outpatient department of the hospital (POS 22). But start with looking around for the G0463...very confusing for sure. Hope this helps.