Results 1 to 2 of 2

Payer Denials

  1. #1
    Casa Grande
    Default Payer Denials
    Exam Training Packages
    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
    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

Similar Threads

  1. Amerigroup payer in nj
    By jennburgel in forum Payer/Health Plan
    Replies: 0
    Last Post: 10-18-2014, 08:40 AM
  2. Payer Guidlines
    By in forum Billing/Reimbursement
    Replies: 7
    Last Post: 08-09-2014, 11:49 PM
  3. E/M Payer question
    By in forum E/M
    Replies: 2
    Last Post: 06-10-2014, 12:43 PM
  4. Payer Address on UB-04
    By Kevinph84 in forum Billing/Reimbursement
    Replies: 0
    Last Post: 06-23-2010, 10:50 AM

Posting Permissions

  • You may not post new threads
  • You may not post replies
  • You may not post attachments
  • You may not edit your posts
Enjoying Our Forums?

AAPC forums are a benefit of membership. Joining AAPC grants you unlimited access, allowing you to post questions and participate with our community of over 150,000 professionals.

Join Now Continue Reading Without Full Access

Already a Member?


Close Message

In addition to full participation on AAPC forums, as a member you will be able to:

  • Access to the largest healthcare job database in the world.
  • Join over 150,000 members of the healthcare network in the world.
  • Be a part of an industry leading organization that drives the business side of healthcare.
  • Save anywhere from 10%-50% with exclusive member discounts on courses, books, study materials, and conferences.
  • Access to discounts at hundreds of restaurants, travel destinations, retail stores, and service providers. AAPC members also have opportunities to save on heath, life, and liability insurance.
  • Become a member of a local chapter and attend regular meetings.