Wiki When is an office visit not billable?

[tag60]

I'm told that to code/bill for an E/M visit, there has to be medical necessity plus the problem is "treated." Our facility, which is heavy on Medicare patients, at times will code a "no charge" for a visit. I struggle at times because I'm unsure what constitutes "treatment" or whether it was necessary for the patient to actually come in. (I've tried researching but I can't seem to find any solid information.)

For example:

Pt comes in for followup of DM. HPI: Pt has no complaints. No exam done (or provider just notes vital signs stable). A/P: DM. Continue as before. Medication refilled (no change in med or dosage). Was this visit "medically necessary"? Was anything really "treated"? Do I code E/M 99211 or 99212, or "no charge" visit? (We have a certain code we use for "no charge" or "not billable").

Or pt returns for lab results. (No HPI, just reason for visit is given. Sometimes the provider will do an exam, but the auditor tells me the exam is not indicated so cannot count.) The lab confirms hyperlipidemia still exists (not a new problem) and provider refills same med, same dose. No counseling done, just told to continue as before. Is anything "treated" when nothing changes? Is this a billablevisit? (But why would the appointment even be made or the provider see the patient if it was not "medically necessary"?)

I'm so confused at times...I hope this question makes sense! (Newbie here, 5 months on the job.)

 

[teresabug]

Good morning! I would like to direct you to an article from HCPro that you can reference re: this topic. I have the same occurences at my job. The webite is www. justcoding.com and use the search terminology of "medical necessity with E and M services". Great article that you can educate your providers with.

Teresa

 

[MP555]

Still confused.Pt with lab results comes to office. Labs show some form of treatment needed or diet.
Results of labs given .How would you code it.If Doc or nurse gave results?

Thanks

 

[thomas7331]

While it's true that services must be medically necessary in order to be covered, medical necessity is a clinical decision and not a coding one, so in my opinion, changing codes based on medical necessity is outside of a coder's scope of training and should only be done in collaboration with providers. A medical necessity determination made in any payer audit would always involve peer reviews, not just coders.

Your employer and providers really should give you guidance on this, and provide a framework for you to know when it is or it not appropriate to involve medical necessity into your coding. In my experience, provider services are rarely unnecessary, but notes perhaps do not always accurately reflect what is really happening, so this is a documentation quality issue, not a coding one. It's important for coders to get this feedback to providers so that they can improve of their documentation. Changing codes or simply not billing services, unless so directed by your employer, doesn't address the real problem.

Your example of a patient coming in for lab results is a typical one of the difficulty of coding something when the notes don't provide enough information to support the necessity of the service. There really isn't an answer as to how to code this because the note is deficient. I'd recommend taking examples like this to your supervisor or manager and explaining the problem this presents. It not only creates work for the coders, but also costs your facility in revenue, creates audit risks and even potentially poses patient care quality issues. It's important for your practice's leadership to be aware of this and to create a process to direct you on how to handle this.