tci E/M Coding Alert - 2013 Issue 7

Reader Question: Provider Holds Ultimate Coding Responsibility

Question: One of our physicians allows his medical assistant to choose his E/M codes. The assistant is not a certified coder and always picks the highest E/M code possible. Is there anything in writing stating that only a certified coder or physician can choose the codes? Pennsylvania Subscriber Answer: There are no written guidelines stating that a physician or certified coder must choose procedure codes. The physician can delegate that responsibility to another person, but needs to understand that doing so does not release him from liability related to the other person’s actions. The physician is ultimately responsible...

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