Wiki To charge or not to charge an e&m

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LauraF1225

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Hello! My REI doctors are trying to bill an e&m along with a venipunture which the patient's see the nurses for. The doctors have been adding this verbiage to the nurse notes: "An additional 10min spent in evaluation and management services independent of any other procedures performed today" followed by their name. There is no information as to what was discussed or done within these 10 minutes. Majority of the time they're connecting the same diagnosis for the venipuncture to the visit, sometimes there a bunch of diagnoses they attach with no documentation to back it up. This is a new thing the department is trying. My coworker and I do not agree with our manager for allowing this.

Is the doctor's sentence of addition time enough to qualify for an e&m being charged?

Thank you!
 
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This statement does not support a separate E/M code. While we can now select the E/M code based on either MDM or time, documenting time alone is not sufficient, there must be a chief complaint that is evaluated and managed. This service is not medically necessary, and it is not appropriate to submit an E/M.

For additional reading:
MLN 006764 Evaluation and Management Services

Medicare Claims Processing Manual, 100-04, chapter 12, Section 30.6.1.B

AAPC Fortify Your Understanding of Medical Necessity
 
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Hi, unless I'm missing something the doctors are documenting work that they did not do and billing for it. If so, while I can't say it is fraud because that requires a finding of criminal guilt, I can say this is improper documentation and coding that's creating improper payments.

I'd also add that even if they ignore the coding compliance exposure they're creating, stating that they had a face-to-face encounter with a patient when they did not really ramps up their medical liability risk.

Even if they are seeing patients, then as noted above it isn't medically necessary and again not billable.

As an aside: Medicare carriers have made it clear that any provider who documents the same time for every encounter is going to get downcoded or denied on audit.

I know this is a tricky situation to be in, you are right to disagree with your manager.
 
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