A clinic physician asks the coder to select a higher-level office E…

Question

A clinic physician asks the coder to select a higher-level office E/M 'because the payer pays better,' even though MDM and time support only a lower level. What should the coder do?

Accepted Answer

Assign the E/M level supported by documentation and refuse knowingly upcoding for reimbursement. — Payment envy isn't a leveling guideline. If the note supports a 99213-type visit, you don't stretch it to a higher code just because the fee schedule looks tastier—that's the classic OIG risk area everyone warns about.

Answer

Upcode as requested and document that reimbursement strategy drove the level.

Answer

Alternate high and low levels across patients to 'average out' risk.

Answer

Report the highest payable E/M in the category whenever the payer fee schedule looks favorable.

A clinic physician asks the coder to select a higher-level office E/M 'because the payer pays better,' even though MDM and time support only a lower level. What should the coder do?

Short Explanation

Full Explanation