I have a couple questions and would like the opinion of other coders/clinics.
How many practices are releasing charges without first reviewing the note to make sure the E&M level chosen by the provider matches the documentation?
How many coders are letting the Dr's choose the level of E&M and just releasing these claims "as is" without review?
and
If the work flow is done like this, what kinds of liability is it to the coder if there have been previous audits done, where level 99215 was chosen by the provider frequently, but the note only supports a 99213. If the coders know this from previous audits, and are now being asked to change workflow to just "release" charges without coding the levels and audit after the fact, what are the liabilities to the coder?
Also, if there is a "new trend" in coder workflow like stated above, is there a compliance plan in place to do audits after the non reviewed/coded release of claims?
Back story...As a coder, I believe notes should be reviewed, and coded correctly PRIOR to the release of claims as the documentation must match the level of service billed. However, I am being told that this is no longer the common practice and that charges should be released with the E&M level the Dr chooses and that audits can be performed after and education on the wrong ones later and that this falls back on the Dr. I do not agree with this and am looking for advice from other coders and getting your thoughts on this debate.
How many practices are releasing charges without first reviewing the note to make sure the E&M level chosen by the provider matches the documentation?
How many coders are letting the Dr's choose the level of E&M and just releasing these claims "as is" without review?
and
If the work flow is done like this, what kinds of liability is it to the coder if there have been previous audits done, where level 99215 was chosen by the provider frequently, but the note only supports a 99213. If the coders know this from previous audits, and are now being asked to change workflow to just "release" charges without coding the levels and audit after the fact, what are the liabilities to the coder?
Also, if there is a "new trend" in coder workflow like stated above, is there a compliance plan in place to do audits after the non reviewed/coded release of claims?
Back story...As a coder, I believe notes should be reviewed, and coded correctly PRIOR to the release of claims as the documentation must match the level of service billed. However, I am being told that this is no longer the common practice and that charges should be released with the E&M level the Dr chooses and that audits can be performed after and education on the wrong ones later and that this falls back on the Dr. I do not agree with this and am looking for advice from other coders and getting your thoughts on this debate.