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Thread: I am posting this a second time, please help

  1. #1

    Unhappy I am posting this a second time, please help

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    We all know that some physicians tend to overload dictation with unecessary ICD-9 codes thinking that it would help the level of visit. I advise my physicians if it is not applicable to the visit do not bill or code it. I need a consensus on how other coders view this scenario.

    Medical Decision Making

    Provider "DICTATED" 4 STABLE chronic illness, only "BILLS" for 2 = 2 problem points

    Level of risk = 2 or more stable chronic illnesses

    Data reviewed = 0


    Medical Complexity - LOW
    Exam - Detailed
    = 99213


    Medical Complexity - Moderate
    Exam - Detailed
    = 99214 "For "dictating" the four problem points even though billed for only two

    I work in a coding facility that I am not able to "kick back" the billing slip for the provider to bill diagnosis that are missed but supported by dictation.

    Any insight would be greatly appreciated!


  2. #2
    Join Date
    Apr 2007
    Greeley, Colorado


    If the other two diagnoses reported are not supported in the documentation as having been addressed or treated, then they are not inclusive to the visit and therefore not countable in the MDM. I think you have a 99213 based on what you posted.
    Lisa Bledsoe, CPC, CPMA

  3. #3


    Hi Lisa,

    Thank you for replying to my message. You see I have providers that will list a quite a number of diagnosis under assessment and only bill for 2 (which equals to 2 problem points if they are both stable). So I see that the providers are short changing themselves if they are being neglectful with marking their superbill. And I know being a coder we should not assume and mark the bill ticket for them. So when I audit them, I have my CPMA, if their dictation is not reflective to the superbill I ding them for it. They're dictation may supprt a level 4 or 5, but if you are billing for only 2 diagnosis and they are stable, I'm sorry but I will lower that level of service based on what they had billed. Remember I do not have the capability to send back the superbill for the physician to accurately mark what has been missed.

    For a level 4 visit follow up you would need:

    1 stable with 1 worsening problem points =3
    2 worsening problem points = 4
    3 stable problem points = 3
    new problem to examiner no additional work up planned =3
    new problem to examiner additional work up planned = 4


    Data reviewed = 1 point for reviewing labs

    Level of risk (moderate) = Either, 2 or more stable chronic illness, one chronic illness with mild exacerbation, or prescription drug management.
    __________________________________________________ _________

    MDM - Moderate

    Thank you Lisa,

    Have a Happy New Year

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