Coding, Classification & Reimbursement

1.  E/M visit required for calling insurance company

Posted 7 days ago
I recently spoke with a primary care doc who said if a patient's
insurance requires that he personally call for peer approval of a
procedure, he requires the patient come in to the office and sit in the
room with him while he makes the call so he can charge for a visit. He
says this is the only way he can afford call all the insurance companies
who require it. He said it typically takes about 20 min. I don't know
if he does a short exam or history during this "phone call" visit, so
I'm having a hard time seeing how he can get a legitimate E/M code from
making the phone call in the patient's presence. Any thoughts?


2.  RE: E/M visit required for calling insurance company

Posted 6 days ago
Hi Lorraine,
My first thought in reading the scenario you described is that there is no medical necessity for an E/M service and you can't bill payers for medically unnecessary services.  I have seen some practices create a "dummy" code for administrative/billing purposes and then bill the patient directly for various administrative services.  These services cannot be billed to insurance/Medicare and the patient must made aware up front that they must pay for this service.  


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Jenny Harvey, RHIT, CPHQ, CPMA, CPC
Manager, Healthcare Consulting
LBMC
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3.  RE: E/M visit required for calling insurance company

Posted 6 days ago
​There has to be medical necessity for the visit.  In order for the physician to get paid for the time on the phone, would not be a medically necessary reason for the patient to present for an appointment, regardless of whether or not he goes through the E/M motions.

Greta

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Greta Ryan, RHIA, CCS, CCS-P
Coding & Compliance Analyst
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4.  RE: E/M visit required for calling insurance company

Posted 6 days ago
Please check your CPT book. There are time based codes for Telephone encounters. You don't want to be on the wrong end of an audit and forfeit your certification for improper coding, but more importantly, I see Fraud written all over this. Just my opinion 

Stacey L Murphy, MPA, RHIA, CPC
AHIMA Approved ICD-10-CM/ICD-10-PCS Trainer
Exam Prep Facilitator

Sent from my iPhone





5.  RE: E/M visit required for calling insurance company

Posted 6 days ago
There are a significant number of health care providers that would benefit from documentation and coding education. With proper training and documentation/coding resources, I am pretty sure that if the patient record is carefully reviewed prior to the visit, the documentation contains diagnostic info that supports medical necessity. 

Stacey L Murphy, MPA, RHIA, CPC
AHIMA Approved ICD-10-CM/ICD-10-PCS Trainer
Exam Prep Facilitator

Sent from my iPhone