Question: Your physician admitted someone as an initial inpatient, however couldn't get all her information. He carried out a comprehensive exam as well as complex medical decision making based on the patient's present condition. Can you give credit for a comprehensive history despite the fact he couldn't obtain a comprehensive ROS (review of systems) because of the patient being mentally confused?
Answer: There is no written rule that you can automatically provide credit for a comprehensive level when all or part (e.g., ROS) of a patient's history is unattainable. Generally, you can only give credit for the level of history that is documented. Remember that the viewpoint may be payer specific, so you must check with your local payer to have clean medical coding and billing claims.
Medical Coding and Billing Tip: Though, in a lot of cases you are permitted to count history toward the level of E/M service you bill even though you are not able to obtain it directly from the patient. However you should document that you made an effort to obtain information about the patient from other sources.
Action: The "Documentation Guidelines for E/M Services" states, "If the physician is unable to obtain a history from the patient or other source, the record should describe the patient's condition or other circumstances which precludes obtaining a history." Consequently, verify that your physician evidently documents the reason the patient is unable to provide a history, and also document his efforts to obtain the patient's history from other sources. This could include family members, other medical personnel, obtaining old medical records (if available) as well as using information from the records to document some of the history components (past medical, family, social).
Base Your Billing Order on RVU Order
Question: You know that as a general rule the highest RVU has essentially a higher billed amount and that while billing you must always put the highest amount first. However when it comes to bilateral surgeries is it right that you would sometimes be wise to put another procedure first as a bilateral code that was done bilateral/unilateral would still be paid at a reduced allowable?
Answer: Yes, you must sometimes put another procedure first. In case the 150 percent amount of the relative value units (RVUs) for a bilateral procedure is the highest, you must put that code first.
Here's why: As the insurer will discount the second and subsequent procedures based on multiple procedure discounts, it's by far the best to list the codes in RVU order, with the highest-paying code listed first. Remember that you should follow this rule of thumb even though your insurer wants you to append modifier 51 (Multiple procedures) before you submit the medical coding and billing claim.
Payers will decide your primary and secondary procedures in one of following listed three ways:
- As per the relative value unit (RVU) order based on the Medicare fee schedule
- As per the insurer's own fee schedule
- In the order in which you listed the codes on your medical coding and billing claim.
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