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Billing an E/M with U/S when pt never saw NP/MD

  1. Default Billing an E/M with U/S when pt never saw NP/MD
    Clearnace Sale
    I need some opinions, mainly because the situation really bugs me! Heres the situation...Pt is on Clomid and receives IUI treatment. So, the week or 2 before the IUI pt comes in at one point every other day for a quick follicle check U/S. U/S tech says "nope, not ready needs to be bigger..come back in 2 days for a recheck. Do you need to talk to a Nurse Practioner?" Pt responds no and is on her way til the next visit. Billing office is billing the 76857 cpt "globally" both TC & PC and an E/M of 99213 or 99214. I got in a huge debate with billing manager (who says shes certified) as to how she is billing a level 4 E/M when NO practitioner ever even entered the room or exchanged a word with the pt???? She states the E/M is for reading/reporting the ultrasound! I reminded her that thats what the professional component of the U/S is for. She didn't seem to know a thing about TC/PC. She then went on to say that U/S techs now have to have special credentialling so they are considered a practitioner and therefore can bill for their time during the visit. Does anyone know of any truth to that statement?? I don't see how a five minute U/S can possibly result in any documentation to support a level 3/level 4 office visit. I mean you can't even bill that going by time spent!!! I don't even think it supports a 99211!! If you went to a free-standing radiology dept with a script for an xray or U/S, the radiologist wouldn't charge you an E/M on top of the radiology code! It's just crazy in my opinion and experience, but the billing manager would hear nothing of it and insisted she was correct and blew me off. Does anyone know of info I could use to prove to her I'm correct?? Or should I just report it to the insurance carrier?

  2. #2
    Milwaukee WI
    Default Absolutely NOT an E/M
    An E/M service requires direct face-to-face evaluation and management of the patient's condition by a recognized provider - i.e. physician, NP, PA

    No way a radiology tech (no matter how much special training s/he has) can charge an E/M of any kind.

    Even if it was a doctor who was running the ultrasound ... when you code the global ultrasound code that INCLUDES the interpretation. Again, no E/M.

    Just a wild guess here ... but are you the patient? If so, definitely report it to your insurance company.

    F Tessa Bartels, CPC, CEMC

  3. Default
    Thank you! And yes I am. That's what makes it so frustrating, that I'm a CPC with over 10 yrs experience in multiple specialties. This woman didn't even stop and listen or research to make sure she was correct. Just would NOT hear anything I said.

  4. #4
    Evansville Indiana
    Default Stick to your guns
    You are most definitely correct. Stick to your guns. I would report it to my insurance company as this is fraudulent billing.

  5. #5
    Default Wow
    Who are they billing the E/M under? I'm sure the provider would really appreciate being informed of the fraud flying out the door under their name.

    I agree you need to report it to the carrier. It would be interesting to see what they are documenting. I know from personal experience many times what they document is not what happened. Might be worth it to get a copy of the records you may have even bigger issues than just whacked out billing....

    Good luck,

    Laura, CPC, CPMA, CEMC

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