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specialty e/m guidelines???? confused

  1. #1
    Default specialty e/m guidelines???? confused
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    our ortho surgeon is under the assumption after talking with another surgeon that since he is a specialist that he can bill 99205 for every new patient is this true? i havent seen anything in the e/m guidelines to constitute this. also he was told by yet another specialists that they bill all new patients under 99455? is this even legal and how would that even be payable for all patients when its not recognized by medicare? i am soo confused any input would be appreciated

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    I'd be very careful to charge only the level that the documentation supports.

    ~L
    CPC, CGSC, COSC

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    No, he cannot bill for 99205 Or 99455 for every patient. The E/M codes are set up for all office/outpatient/or ambulatory facility physicians. There is a reason there are levels to the E/M codes and it is not based on the specialty but rather the intensity of information being review by the physician for each patient. I would tell your doctor to show you in writting where it says that specialist bill only 99205 to back up what he is saying because there is nothing in the CPT book that Medicare and most insurance widely use, to support what he is saying and being told. I would also caution him to not determine his billing practices based off of word of mouth but by concrete evidence because the goverment doesn't mess around when it comes to E/M coding and he could get severly fined for this if they catch wind of it.

  4. #4
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    Sometimes doctor's lounges can be a dangerous thing! I often have to remind my docs of some billing rules and assure them that other offices are not billing everything at level five. Especially new patients and consults (I think you meant 99205 and 99245).
    Jerri, CPC

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    Quote Originally Posted by michellelgrd View Post
    our ortho surgeon is under the assumption after talking with another surgeon that since he is a specialist that he can bill 99205 for every new patient is this true? i havent seen anything in the e/m guidelines to constitute this. also he was told by yet another specialists that they bill all new patients under 99455? is this even legal and how would that even be payable for all patients when its not recognized by medicare? i am soo confused any input would be appreciated
    Your level of E/M is based on medical necessity/complexity of medical decision making and your documentation of of all three components of history, exam, and medical decision making or if over 50% of teh total visit was spent in face to face counseling time.

    We are colon and rectal surgeons (sub speciality) and our e/m charges follow the Medicare Compartive Billing Reports for our speciality and our locality. We audit regularly to look for over and under billing. Just remember that if you are an outlier with any insurance company than you should be expected to be audited. Just audit about 10 of your MDs NPT and Consults to show that not every one meets 99205 or 99245. Also, you can print the 1995 or 1997 E/M guidelines from the Medicare site to support your eductaion.

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