Are there any rules or guidelines from Medicare or anyone else that says the doctor is required to select the E/M code? I am wondering if the physician allows his staff member who is a certified coder to select his E/M code based on review of his documentation, if this is legal.
The E/M should reflect the work involved and must be supported by the documentation. It doesn't matter who chooses the E/M level as long as the level is supported by the documentation as well as medical necessity. Ultimately it is the physician that is responsible for what is billed to the patient. When he puts his name on the HCFA he is stating that all the procedures/services listed on the HCFA were performed by him and that they were medically necessary, and that there is medical documentation to support everything he has done.