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NEED QUICK response! Coding Policy...Fraud?

  1. #11
    North Carolina
    Medical Coding Books
    I do understand your view, Laura, and this may be why some physicians are requesting the patients to reschedule their PE's and choose to address the "problem" that is present. I think Medicare developed this "carve out" rule so that the beneficiaries would not be subjected to unfair monetary liabilities. If a physician chooses to treat a "problem" at the same time as the wellness exam, it does make sense that some of the history, exam and MDM would be credited to the problem oriented visit...there is a portion of the visit that is not dedicated solely to the wellness exam. As a result, Medicare created a "window" of medical necessity for their liability. I don't necessarily agree with all of Medicare's rules, guidances, etc, but if it's in "black and white", I follow those guidelines. I don't want to compromise abuse. I know what's correct...I know what can be billed...therefore, we have to put it to paper. Senior citizens are being encouraged to report fraud/abuse. I just don't want to be on the receiving end of an audit

  2. Default Medicare wellness and modifer 25
    So how do we manage the provider that wants to bill for the wellness and a new diagnosis with a separate E&M with a 25 modifier?

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