Don't Rely On Medical Billing Forums—Documentation Is The Key

All too often we receive questions regarding specific medical billing issues and matching medical codes in our forum; but that's not just our Medical Billing Forum alone, that's ANY medical coding and billing forum on the Internet is packed with questions regarding specific (CPT) codes and urgent requests for help. That way, if something goes wrong they have someone else to blame.

Medical Coding Questions Posted in a Forum

Unfortunately, this tells us that there are medical coders (and medical billers) who, quite frankly, have no clue; they are inadequately trained, or self-trained, and when they hit a wall, they post their question in a forum in hopes to get answers or find someone (anyone!!!) to give them approval of codes they have somehow come up with themselves. This could be a student with a test question, or homework assignment, or a medical coder, or biller already working but that is in over his or her head. One example of such requests posted to our medical billing forum is asking for help with a specific CPT code. It reads:

"I bill for a rheumatologist. I am familiar with most codes that he uses but last week he gave XYZ-medication (*brand name removed - not relevant for this example) to one of his patients who had a severe drug reaction. There was considerable disruption in the office and the direct observation lasted 2 hours. The doctor wants me to bill for his observation services but I am not sure which code to use. I was thinking may be 99058 will fit the bill, but the doctor insists that the code should be time specific since he spent two hours on the patient's care. Can someone please help?"

Medical coding must never be performed without first looking at the original documentation and the final decisions regarding coding issues rest with the provider. It must be clearly understood that a forum is not an official organization, agency, or anything else that provides a final decision regarding coding or billing issues. A forum is not here to code visits, to train a visitor how to code, or to recommend which codes to select. All a forum, its members and/or guests do is provide limited guidance.  Guidance is limited to what is presented by a poster, however, what is presented may, or may not be true, accurate or correct.

The CMS website, specifically at https://www.cms.gov/MLNEdWebGuide/25_EMDOC.asp states:

"Providers are responsible for the correct submission of claims and response to any remittance advice in accordance with current laws, regulations and standards."

The patient's medical record must show detailed entries as to time, who did what, when, for how long, was it the doctor who monitored the patient directly, or was it delegated to a nurse or a medical assistant, what directives were given, was emergency intervention provided, and if so, how much total direct hands on and face-to-face time from the doctor was involved? When it comes to accurate medical coding, any code selected must be:

1. medically necessary
2. documented as being rendered
3. the proper code for the documented services rendered.

Telling a patient to sit in the waiting room for 30 minutes before they can leave after an injection and direct face-to-face attention after an acute reaction can both be described as monitoring, but it doesn't always mean it can be billed it at a higher level.

The Doctor Makes the Final Decision

The provider knows what was done and everything must be coded as it was documented in the patient's records. A medical coder can research a subject, provide suggestions and present supporting documentation from the proper sources to to make a point, however, the final decision rests with the doctor.

Documentation is the key.