Time vs MDM

KoBee

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Is it safe to change of level of service based on MDM if the provider is documenting TIME when you clearly read there is no way they spend that amount of time on a minor problem? or is that assuming and we should select level of service based on the time the provider documented?
 

thranowski

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Our providers document time at each visit as a standard. I bill whichever is higher. It doesn't say who has to decide which to use, as far as I know.

However, our providers are also required to justify the time spent. They can't just say they spent 40 minutes on a common cold, they have to say where they spent that time. Example, if the patient had a lot of questions, if they're a complicated patient and the provider had to spend time reviewing prior records, etc. I will send it back to the provider asking them to justify the time spent if I don't feel it'll fly for insurance.
 

thomas7331

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Is it safe to change of level of service based on MDM if the provider is documenting TIME when you clearly read there is no way they spend that amount of time on a minor problem? or is that assuming and we should select level of service based on the time the provider documented?
As a coder, we're supposed to code based on what is documented and doing otherwise it technically incorrect. However, it sounds like you have doubts about either the accuracy or the medical necessity of the time that is being documented. It's a legitimate concern, as the previous post has pointed out, but second-guessing your provider is not the correct approach. There may be reasons for that amount of time that a coder without the clinical background doesn't completely understand, or it may be that the provider needs to put in more detail to make this clearer in the event that a payer auditor questioned it the same way you are. That is something you need to discuss with your manager or your provider - let them know that consistently billing high E/M levels for minor problems without explanation could certainly raise questions over time and invite an audit, and that documentation needs to support what the provider is billing. I would stick to the coding guidelines and code what is documented unless your employer agrees with you and gives you some guidelines on when and in what situations you may use your own judgment to downcode based on medical necessity.
 
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KoBee

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As a coder, we're supposed to code based on what is documented and doing otherwise it technically incorrect. However, it sounds like you have doubts about either the accuracy or the medical necessity of the time that is being documented. It's a legitimate concern, as the previous post has pointed out, but second-guessing your provider is not the correct approach. There may be reasons for that amount of time that a coder without the clinical background doesn't completely understand, or it may be that the provider needs to put in more detail to make this clearer in the event that a payer auditor questioned it the same way you are. That is something you need to discuss with your manager or your provider - let them know that consistently billing high E/M levels for minor problems without explanation could certainly raise questions over time and invite an audit, and that documentation needs to support what the provider is billing. I would stick to the coding guidelines and code what is documented unless your employer agrees with you and gives you some guidelines on when and in what situations you may use your own judgment to downcode based on medical necessity.
Thank you for the feedback, definitely a conversation that needs to happen to prevent an audit.
 
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