Basically, you will simply decide the level of service (i.e., how much work you did) and record it in the patient’s chart. Most offices have a form for this purpose. It may be called a “superbill,” “charge sheet,” “checkout sheet,” etc. When you are ready to code, you simply mark the level of service that you did. In offices with electronic records, you may have an electronic method of coding.
You may be wondering, “Can’t my office staff do this for me? Isn’t that their job?” Unfortunately, for all practical purposes, the answer is no. First, you are the physician, and you know best the amount of work you did for the patient. Secondly, it takes time to find charts, open charts, read doctor’s handwriting, and professionally review charts. It would be a full-time job for a trained person to review every chart you use daily. In the real world, nobody is going to pay for a full-time position to do something that you could have done by simply checking a box. Third, when many patients check out, your office will need to know what to charge them. Some people will have to make a payment at the time they leave the office, depending on their insurance. Billing a patient later becomes confusing to them, increases your costs, and lowers the likelihood that you will get fully paid for your services.
“Can’t the computer do that for me?” Again, for practical purposes, the answer is no. Computers can be a great help, but they often misunderstand the information you input. It is YOUR job to know when this happens. It is virtually impossible to document a patient visit well from a medical-legal standpoint by simply checking boxes. Coding is partly based on judgment and partly subjective, which a computer cannot do. If you input data in a way that is not “standard” for the computer’s formula (which is often a very strict criteria), it will not “see” all of the work you do. Computer programmers, after all, are not often trained in medical coding. Nor are they legally responsible for coding errors. It is your job to know when errors happen and to correct the code appropriately.
“Can’t I just code a 99213 for everyone?” If you are self-employed and do not mind being poor, then yes. If you work with a partner or as an employee (which most starting physicians do), then you will be watched and critiqued. You will likely have a bonus (or penalty) for the amount of revenue that you bring in. Coding the same code for every patient is inappropriate.
Medical Coding and Billing For Residents 