coding for self-pay

I am trying to find documentation on what is the proper way to code an office visit E/M for a self-pay or uninsured patient when the physician wants to charge the patient less. Ex: documentation and medical neccessity supports a level 3 E/M service but physician only wants to charge for a level 1 service. I need to know do we code the accurate level 3 or is it appropriate to code the level 1, and are you aware of any resources that state this in writing so I can have some form of proof for the physician?

Thanks for all feedback!!

coding for self pay

Typically, the coding is the same. You can't have a policy that charges self pay patients less than you charge Medicare patients for the same service.

If the patient has financial hardship, however, you can provide a charity or financial hardship discount. (You can't waive the co-pay for insured patients) You should have a policy in place for this.

You can also provide a cash discount for patients who pay at the time of service.

Maybe someone who knows in what manuals/OIG reports this is described can chime in.

What I do...

is bill a level 2 visit. I can justify underbilling to level 2 ("that coding system is so complicated!") but not level 1 (since this is a nurse visit). Then you can apply your cash discount policy and get your money. It is a shame we have to go thru such a hassle to be nice guys!

self-pay

Be careful
Medicare has a rule that states you cannot bill lower than what is charged to Medicare patient for same service code. But, Medicare has no say on self-pay (unless a Medicare patient). I do not have all facts but would advise a legal opinion. There are those that say, Yes, you can charge self-pay patients less than Medicare, but you want to make it clear that this lower charge is not your “usual and customary fee” (lest Medicare decides to pay you that much, too). So, you might offer it only to self-pay patients who pay in full at the time of service since there are obvious cost savings to you. Or you might reconsider the lower fee if self-pay patients make up a sizeable portion of your patient base. If you do it, do it judiciously.

self-pay

Thank you for the help. I am pretty clear on how to handle actually giving the patient the discount. But I am still unclear on the coding part. To me, downcoding screams violations and fraud but I haven't found any documentation that says it. What I seem to find is documentation that says "physicians downcode to be safe" or "physicians are hurting themselves when they downcode because of lost revenue" but is there anywhere that says downcoding is actually a violation the same as upcoding is?

coding for self-pay

My understanding is to bill the correct code for what was done. The provider needs to document that he is allowing for financial hardship and discounting his charge for this service only. We then apply the discount after the charge has been posted.

Codapedia editor is correct...

Downcoding a level 3 service to a level 2 service merely to charge less is just plain wrong. A clearly written and followed charity care policy lets you enter the level 3 service charge, and apply a discount, so the patient gets a bill he can afford, and we really want them to pay at the time of service. As the previous reply said, the provider should add a statement in the documentation that charity care is to be used because of patient's financial situation. Patients with insurance coverage for their visits are not eligible for a charity care discount. In our mental health practice, patients provide documentation (1040s and/or W-2 or gov't benefit statements) and apply after initial evaluation but prior to their course of treatment.

Can't I just be a nice guy???

It is not wrong to down code- it is my business, I own it, I can charge what I want to someone who has no contract with me that sets fees. Medicare has no right to access charts of patients that are not covered by medicare and if they want to raid me and audit my charts from the last 18 years to find the 10 self pay patients, let 'em! If I was a clinic with lots of self-pay then a policy, a procedure and documentation might be reasonable but I am not spending $5,000 on a lawyer to set up a system to be a nice person. I'm drawing the line!!!!!!!!!!!!!

downcoding

Since documentation justifies level of care looks to me as if the doc knows the patient is indigent, he would do as low a level service as he can get by with. Documentation is the key to billing the visit and the less documentation the lower the code. This is not illegal, he just makes sure he doesn't put more in the doc than absolutely necessary.