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Thread: E/m level for self pay pts?

  1. #1

    Default E/m level for self pay pts?

    AAPC: Back to School
    Our office offers 20% discount for pts with no insurance for medical visits. I was told the Drs can undercode the level of service for self pay pts if they want to, and also give the 20% discount on top of that, because those charts never get audited. I think you still have to code to the correct E/M level based on the documentation regardless if you're billing the insurance or pt is self pay. I can't find anything on websites regarding this. Does anyone know what is correct? Thanks!

  2. #2
    Join Date
    Apr 2007
    Columbia, MO


    You can NEVER under code an encounter. What would happen (as it sometimes does) that the patient suddenly remembers they do have insurance? Always do what is documented.

    Debra A. Mitchell, MSPH, CPC-H

  3. #3


    Thank you. I agree. You never under code no matter what and have tried to no avail educating my mgr and Dr on this. You always code according to the documentation. But this is what I have been told they will do. Besides, an audit is an audit whether the pt has insurance or not.

  4. #4
    Join Date
    Apr 2007


    You can potentially run into Anti-kickback lawsuits for downcoding self-pay patients. You have a contract with insurance companies to bill for set rates based on documentation guidelines. There cannot be any different treatment with a self pay patient. And what happens if Mr. Self Pay patient starts talking to Mr. Insurance patient and they start comparing notes about what each was charged? The discount is fine, but the downcode is really a no-no.
    Elaine Guest, CPMA, CHCA, CPC

  5. #5
    Join Date
    Apr 2007


    Also what most doctors & coding/billing staff need to always keep in mind is that the patients' medical record/chart note (regardless of patients' insurance status) IS A LEGAL DOCUMENT- and as such should be treated the same across the board to ensure proper & COMPLETE DOCUMENTATION of that patients' medical history. What if this patient w/no insurance has been getting the scenerio described above (notes not as complete- downcoded on top of discount)and then decides to see/change to anorther physician & requests copies of all of their medical records...??? or better yet, patient involved in lawsuit due to injury from someone elses' negligent actions whom you've treated & now lawyers want/need all the exam notes for this patients' case....??... this is serious & ALL PATIENTS' EXAM NOTES/CHARTS MUST BE COMPLETE TO THEIR FULLEST REGARDLESS OF PATIENTS' INSURANCE STATUS OR ABILITY TO PAY.

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