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Thread: Auditing Question

  1. #1
    Join Date
    Apr 2007
    Colorado Springs, CO

    Default Auditing Question

    AAPC: Back to School
    HELP! I need advise. I am currently performing random audits on few providers. I came across a follow up appt for chest pain after a stay in the hospital. Looking back through the record pt’s first visit was due to heartburn/ reflux symptoms. Then another follow up visit for the same problem in 2008. Per the note there is enough documentation for a level 5 based upon History and exam. The MDM is low, as there were no tests ordered only a modification made to Rx. Pt has Medicare and with the MDM being low I don’t feel a level 5 visit should be billed. What do you think?

  2. #2
    Join Date
    Apr 2007


    I would say you are safe in billing a level 5 visit as you stated the documentation substantiates level 5 for the History and Exam based on E/M guidelines that state you only need 2 of the 3 elements on an established patient visit. I would caution however, that the presenting problem does not seem to warrant the level 5 code.

    DBailey, CPC, CPC-H, CPMA
    Last edited by dbailey; 05-11-2010 at 10:42 AM.

  3. #3
    Join Date
    Apr 2007
    North Carolina


    Just a word of caution...

    Medical necessity of a service is the overarching criterion for payment in addition to the individual requirements of a CPT code. It would not be medically necessary or appropriate to bill a higher level of evaluation and management service when a lower level of service is warranted. The volume of documentation should not be the primary influence upon which a specific level of service is billed. Documentation should support the level of service reported. The service should be documented during, or as soon as practicable after it is provided in order to maintain an accurate medical record.

    (MCR Claims Processing Manual Chapter 12)

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