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change to subs if not enough info for level 1??

  1. Default change to subs if not enough info for level 1??
    Medical Coding Books
    An initial hospital visit even at it's lowest requires:

    Hx: detailed
    exam: detailed
    MDM: low

    You need 3 out of 3....what if I can't get 3 out of 3 even at the lowest level?
    Do I code the lowest initial anyway or drop down to a subsequent?

    Amanda, CPC
    Urology coder

  2. #2
    Location
    Columbia, MO
    Posts
    12,529
    Default
    I have always been told to drop it to a subsequent level, if you are the consulting provider. If you are the admitting provider I was instructed to query the physician for additional documentation or use the unlisted, or have the provider change from inpatient to observation status.

    Debra A. Mitchell, MSPH, CPC-H

  3. Default
    Thank Debra! This is a case where more documentation was requested from the admitting physician but it was coming up on timely filing so about to lose the whole charge all together. As we all know, some are not the greatest at staying on top of discrepencies, etc. If he was in a Outpatient status-it would still be initial which still requires the same levels with the 3 out of 3. And he wasn't the consulting. He was the admitting. So, when everything has been done that can be done (with requesting more documentation and all) I wonder what I would have to resort to? The lowest initial level or subsequent? I thought I read somewhere that Medicare says if it's an initial hospital vist, it must be billed as initial.

    Amanda, CPC
    Urology coder

  4. Default
    Oh yea...you said unlisted code. Oh man, sure don't want to have to resort to that...uhg! Don't you have to send in a special report and all?

    Amanda, CPC
    Urology coder

  5. #5
    Location
    Ellenville, New York
    Posts
    1,176
    Default
    Quote Originally Posted by AmandaW View Post
    Thank Debra! This is a case where more documentation was requested from the admitting physician but it was coming up on timely filing so about to lose the whole charge all together. As we all know, some are not the greatest at staying on top of discrepencies, etc. If he was in a Outpatient status-it would still be initial which still requires the same levels with the 3 out of 3. And he wasn't the consulting. He was the admitting. So, when everything has been done that can be done (with requesting more documentation and all) I wonder what I would have to resort to? The lowest initial level or subsequent? I thought I read somewhere that Medicare says if it's an initial hospital vist, it must be billed as initial.
    If this is the case (outpatient), then you are correct that 3 of 3 is still needed, but if the HX and/or Exam are PF or EPF, you can still code level 1 or 2 visits as appropriate. The requirement for a minimum of detailed Hx and exam are only for initial inpatient visits.

    Deborah expressed my other thoughts already and very succinctly, if the provider is the consultant or for querying. Thank you.
    Last edited by MnTwins29; 10-07-2011 at 01:55 PM. Reason: Additional information

    Lance Smith, MPA, COC, CPMA, CEMC, RHIT, CCS-P, CHC, CHPC

    Director, Health Information Management
    HealthAlliance of the Hudson Valley
    Kingston, NY


    2016 Secretary
    Ellenville, NY Local Chapter

  6. Default
    Right. The initial visit is what I'm questioning.

    Amanda, CPC
    Urology coder

  7. Default
    Initial AND Inpatient.

    Amanda, CPC
    Urology coder

  8. Default
    I have never heard of changing from inpatient to outpatient just because the admitting cant meet criteria. All of the other consulting physicians who have already billed as inpatient are going to be awfully angry at you if you do this, as well as the hospital and the patient who has to pay all of the outpatient copays. Plus you have to inform the patient of a status change while they are still in the hospital. To me, if the physician has not given you enough documentation after repeated requests that is their fault and they will learn when they start to lose revenue.

  9. Default
    Yeah, I never heard of changing it either until the other day from one of my fellow coder friends. I definetly think the Dr. should get the lowest-I just hope as the certified coder I will be ok since I billed something that doesn't even meet the lowest criteria. But I didn't see any other option...

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