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Thread: Payer Denials

  1. #1
    Join Date
    Apr 2007
    Casa Grande

    Default Payer Denials

    AAPC: Back to School
    I have a payer who is reimbursing EM based on 1997 guidelines based on the EOB. In addition to stating payment has been made based on the 97 guidelines, a letter is attached stating a review was conducted using CPT/AMA EM Guidelines and 1997 Documentation Guidelines and chastising the provider for using time to select the EM level. Time is not documented nor used to select EM. Any thoughts on how I can fight this using the arguement that use of 95 and/or 97 should be used when reviewing/reimbursing EM services? Any guidance would be greatly appreciated.

    President, Casa Grande Chapter

  2. #2
    Join Date
    Apr 2007
    Columbia, MO


    Payers usually use the 97 guidelines for audit purposes, however assuming your contract allows, you are allowed to select either 97 or 95. You should have it stated in your policy and procedures manual which guidelines your provider follows. As long as time is stated in the providers documented note then you should be able to use that providing all criteria for time based coding has been met. Some carries now require the provider document time as time in and time out style. Time cannot be tracked in the EMR nor in the nurses note. To be used to select the E&M level it must be in the progress note from the provider

    Debra A. Mitchell, MSPH, CPC-H

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