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exam question

  1. Default exam question
    Medical Coding Books
    For the exam how would you answer this question:

    If the coder/auditor dosesn't have enough information to code a service, should she/he :

    Ask the physician for clarity

    go back to the documentation

    go with what is there and code to a low level

    Thanks, any information you can give me regarding this would be great !!

  2. #2
    I think it depends on the documentation and the kind of visit. We have a physician who goes to Inpatient Rehab facility and does a hand written initial consultation note. From that note, it does not meet the criteria to bill 99221 so we bill 99499 when billing Medicare, which they process. I think you would want to talk to the physician or compare to a superbill which would have the level he believes it is to make sure he is aware of the requirements for the certain E/M service he is providing.

  3. Default
    thanks so much I thought this was the answer but just wanted to check !!

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