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How would this be formatted?

  1. #1
    Tacoma, WA
    Default How would this be formatted?
    Medical Coding Books
    I'm currently a medical transcriptionist and will be completing the coding course in a few weeks. I have a dictation from one of our doctors and need help with formatting:
    Dr. X always starts his dictations with a subtitle describing the type of service (he's the only one I know of who does this); for instance, I am working on a report right now where he dictates:

    "This is a level 4, 99214 check back with a number 25 E/M modifier and a number 51 E/M modifier on patient xxx..."

    Would this translate to
    LEVEL 4, 99214-25-51 CHECK BACK

    I searched my textbook and flipped through the CPT and the workbook and couldn't find info on coding multiple modifiers so I am not sure.

  2. Default
    I would have several questions..........

    1) mod -51 is not appropriate with an E&M code

    2) is this a note to the coder on how he wants this encounter coded? Meaning instead of using a superbill he is noting his coding as a pre-statement to his visit documentation. Does the coder see this pre-statement?

    3) I really wonder how an auditor would look at this. Would it be viewed he is dictating the note to meet his stated E&M level rather than the code being assigned based on what was done (medical necessity)
    Last edited by sbicknell; 06-11-2010 at 03:39 PM.

  3. #3
    Tacoma, WA
    Well, now that you mention it, I remember that -51 would be inappropriate!

    He nearly always starts his dictations this way, and I have always transcribed this as a subtitle in the report, but I would spell out the word modifier...and not append the modifier to the E/M (out of ignorance of coding conventions)...this is the first time I can recall that he has listed a second modifier.

    Thanks for your helpful feedback!! I'll put this in QA.

  4. Default
    I have just never seen a physician start his note with that kind of coding statement. When the note is sent back to the Physician who made the referral/consult request, dose this coding statement remain in the note? I think you're right to have QA look at this. I wonder if other physicians in the practice are aware that he is doing this

  5. #5
    Tacoma, WA
    I have to say, too, that I'm quite sure this goes through a coder before it's reported for billing.

  6. #6
    Tacoma, WA
    I don't know...I did just get confirmation that a coder looks at it before billing takes place, and that person probably just rolls her eyes. He's trying to be helpful, but I'm learning a little knowledge can be dangerous!!!!

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