Billing rules and regulations surrounding documentation are very complicated, and at times, one rule will “trump” another rule. It is easy to have a vast knowledge of coding and billing but at the same time misunderstand or misinterpret the application of a particular rule.
Those who have attended our seminars have heard us say many times to beware of the opinions and knowledge of others, whether they’re a colleague, employee, consultant, or article author. You must always consider the source and weigh your opinion accordingly. Keep in mind that your certified coder may have a wealth of knowledge on CPT and ICD-9 coding, but may not have been taught or tested on Medicare billing rules and regulations. Our philosophy has always been, “Trust, but verify.” In resolving disputes or disagreements on coding issues, one must also keep the hierarchy of coding rules in mind. Although CPT is the basis and foundation for all coding, payer rules always trump CPT rules. When we bill for services, we are governed by “contract law,” and therefore any set of payer rules for which we have signed a contract will override CPT rules.
Also, Medicare rules may or may not apply to private payers. Private payers have the option of using CPT rules, adopting Medicare rules, or developing their own rules. For private payers, it’s usually a combination of all three.
Here are some common coding myths or disputes between coders and physicians that we have encountered and our responses.
“My certified coder tells me that I cannot bill higher than level 3 for a complicated consult performed at the hospital on an unconscious patient, because I did not have a complete review of systems.”
Granted, a fourth- and fifth-level new patient or consult code requires a complete review of systems according to the documentation guidelines. However, the rules are clear that if a patient is unconscious or unable to respond to history questions, you are automatically granted a level 5 history according to Medicare documentation guidelines, which state: “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 circumstance which precludes obtaining a history.”
The subject is also discussed in the CPT Assistant: “Add a clear note that, when a history cannot be obtained due to specific patient conditions (eg, inability to communicate urgent, emergent situation, etc.), the history is deemed ‘comprehensive’ for coding and documentation purposes.”
“You cannot capture a high-level history on a vasectomy patient because you cannot capture four bullet points on the History of Present Illness.”
A third-, fourth-, and fifth-level new patient or consult code requires four of the eight bullet points for a history of present illness. If you are willing to think outside the box on such issues as fertility and infertility, you can capture at least four elements on the history. For example, location is always a given, duration can be addressed by stating time frames for considering a change in fertility, there are usually associated signs and symptoms such as the ability to have intercourse and an erection, and certainly modifying factors—and at times contexts—can be captured as well, such as number of children and ages of children.
