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Coding "Work Around" Is this OK?

  1. Default Coding "Work Around" Is this OK?
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    A payer of ours will only authorize one visit at a time of 99203, 99214, and 99242.

    As a work around, our billing system is set up to convert those codes to a 99205.

    I have only been with the company for a few weeks and this process was in place prior to employment. I question whether this is ok to be doing???

  2. #2
    Columbia, MO
    I am not sure what you mean by one visit at a time. One visit per patient per day? or only one of either of those levels for the practice per day? Also you can NEVER just assign a level as a work around for anything. Documentation must support the level submitted or it can be potentially a fraudulent submission.

    Debra A. Mitchell, MSPH, CPC-H

  3. Default
    Sorry if I was unclear.

    The insurance company will only approve one 99214...then want a new auth submitted for the next 99214 and so on.

    Our patients come in every week and with these limitations, it's impossible to keep ahead of the auth game.

  4. #4
    Columbia, MO
    Ok then you must get the new auth. You absolutely cannot just charge anyother level other than that which is documented. Over coding is wrong and undercoding is wrong. And to convert a 99214 to a 99205??? I am surprised this has not been questioned before, for charging a new pt level for an estb patient. The payers set it up this way and that is the way it must be played out. And to be honest if this patient is comming in weekly I kind of agree that every visit could not be a 99214. Also only one consult and only one new patient visit per patient.
    Now you say they will approve one 99214 or one 99203, or one 99242 you mean per patient?

    Debra A. Mitchell, MSPH, CPC-H

  5. Default
    yes. Per patient.

  6. #6
    Columbia, MO
    Ok then I tend to agree with the payer. If you have a patient that comes in weekly or monthly or even every 3 months. There is no way to have more than one 99203 or 99242 unless you have different specialists in your practice, and then I do agree with needing a new auth each time. Also the 99214, every encounter cannot be a 99214. It sounds to me like this payer has performed some post audits and made the determination that they need to verify visits of a certain nature (99203, 99214, 99242).
    I would encourage you to stop this "work around" process. It is unethical.

    Debra A. Mitchell, MSPH, CPC-H

  7. Default
    Thank you so much for the input -- I thought it seemed odd!

    It appears the new gal has opened a can of worms!

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