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Perinatology Audit

  1. #1
    Lightbulb Perinatology Audit
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    I am being asked to do an audit in our perinatology office. The docs are billing out office visits and an ultrasound in 9 out of 10 times. I am only finding the ultrasound report. I was told I could use the ultrasound report for documentation for the office visit. This just doesn't seem right to me and I was wondering if anyone out there specializes in Perinatology that could guide me through this audit. I need this info ASAP! Thanks!

  2. #2
    Location
    Evansville Indiana
    Posts
    451
    Default ultrasound
    Who is telling you that you can use the ultrasound report as documentation of an E&M? An ultrasound report is just that a report. It can be used to bill the professional portion of the ultrasound. An E&M requires the physician to physically see the patient and perform at least two of the three elements(for established patients). I would refer to the guidelines as stated in the CPT book. If you could use the report to bill an E&M, radiologists would be able to bill an E&M for every xray that they performed!

  3. #3
    Default
    I have had this problem in the past too.

    What mine was doing was the doctor actually did the u/s and while doing it talked to the patient. She then tried to bill the E/M based on time in addition to the u/s. Problem is you can't count time if another billable procedure (the u/s) is being done at the same time. It took awhile but I finally got her to stop. She also tried to say that her patient is the baby so she should get credit for E/M during u/s for that reason as well. That doesn't work either.

    We actually had so many errors in that department they were on a 100% audit before anything was billed. This was just one of many issues.

    Laura, CPC, CPMA, CEMC

  4. #4
    Location
    Milwaukee WI
    Posts
    4,466
    Default Agree ... but
    I agree with the previous posts. You cannot double dip the time spent in the US with the time spent in E/M.

    HOWEVER ... just because you have only one piece of paper - in this case titled Ultrasound Report - doesn't mean that you do not have documentation for an E/M service.

    I know physicians who just lump everything together in one document. It is up to the coder to decipher which part of the documentation is the E/M and which part the procedure.

    If, in fact, you have documentation of an E/M service buried in the ultrasound report then you can code the E/M service - as documented.

    Could this be the source of the confusion?

    Hope that helps.

    F Tessa Bartels, CPC, CEMC

  5. #5
    Default
    Thank you for all that replied! The doctors were told they could do this by my supervisor so I don't see this changing any time soon. I do believe they are lumping everything into this US report AND they are using the consultation done by the Genetics counselor as part of their documentation by signing their consultation reports. With the Genetics report I end up with a very comprehensive history but my confusion lies with the rest of the required key components. What other than GU can I report for the Review of Systems? They hardly ever meet the high level of services they are billing because of this. Does the US of the babies anatomy replace an exam on the mother? The MDM is usually moderate because of the risks involved with the pregnancy. It's not such an issue if they are an established patient but when they are billing out level 4 & 5 consultations the documentation doesn't support the level. Any advice on pulling the key components out would be greatly appreciated. Thanks

  6. #6
    Default
    I'm running into a similar situation, my MFM provider just approached me to see if she could put her e/m documentation in her u/s report to expedite her dictation process. We have a sonographer who performs the u/s and the doctor reads it and if needed sees the patient. Most of the time her e/m level is determined by face to face time spent with the patient (again doctor does not do the u/s). Would that then be ok for her to document it all together and still bill the e/m & u/s too? Could that be what your doctors are doing mindyanna?

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