6565 wk 8

            The article chosen discusses determining the appropriate level of evaluation and management and choosing the correct billing codes for each patient. The author, Harry Goldsmith (2013), looks are three guidelines to consider prior to choosing billing codes including: the number of possible diagnoses and management options, the complexity of medical records, diagnostics tests and the other information that needs to be reviewed or analyzed, and the risk of significant complications such as morbidity and mortality with possible management options. Goldsmith (2013) also suggests obtaining a subscription for Codingline. Codlingline is a monthly subscription that you can receive via email or mail that provides information regarding what should be included in medical decision making and risk factors to determine proper coding. Goldsmith (2013) pointed out that there is no “one size fits all,” and the level of risk should be determined by the patient’s situation. Most importantly it is important to document all the diagnoses and management options. When considering a billing situation for evaluation and management, the medical record and patient encounter needs to include the assessment, diagnosis and conditions discussed and management options. Is this a new diagnosis? Is this an established problem? Is the problem controlled, improved or resolving? These questions can help determine the medical decision making value to determine a proper billing code.

            A NP must understand the importance of using appropriate CPT and ICD codes whether they are in an independent or collaborative practice. A billable visit is a face to face visit and the practitioner must distinguish between an established or new patient (Buppert, 2015). The medical record documentation must support the level of care that the provider billed. If the provider does not have the knowledge to choose the proper codes and document thoroughly they will lose money due to insufficient billing.

            Goldsmith (2013) discusses the importance of considering each individual’s situation to determine the complexity of the diagnosis. Details of the appointment should be documented to support the chosen billing code and service level. A NP who consistently uses higher level codes may be recognized by Medicare and could possibly be investigated for billing for a higher level of service. Using a higher code to obtain a larger fee is under the category of false claims (Buppert, 2015). A provider who uses lower codes will produce low revenues for the practice. Any consistency in coding without proper documentation supporting either lower or higher codes will result in an audit by the Medicare carrier. If the audit shows improper documentation or coding, the provider could be fined, face criminal prosecution, lose Medicare provider status, or even lose their license (Buppert, 2015).

            All providers should have an idea of what each code comprises. New providers should have a reference to follow if they have a hard time determining the complexity of the client or determining the level of service. There are many resources available and charts and tables that provide good information regarding proper coding.

References

Buppert, C. (2015). Reimbursement for nurse practitioner services. In Nurse Practtioner’s Business Practice and Legal Guide (5th ed.). (303-319. Burlington, MA: Jones & Bartlett.

Goldsmith, H. (2013). E/M coding: Medical decision-making in the making. Podiatry Management, 1. Retrieved from Walden Library Database.