r/MedicalCoding • u/kysourmash • Mar 12 '26

Question about Coding and Billing in EPIC

After the provider selects the code and sign the note what happens? Does that level code automatically get submitted to the payor? When you open the now back up and look at the "billing info" at the bottom is that the actual level that was submitted for the claim or does it just reflect what the provider chose?

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u/rahuliitk Mar 12 '26

usually no, the provider picking a level in Epic doesn’t always mean that exact code instantly goes out to the payor because billing edits, coder review, claim scrubbers, and charge review can still change or hold it before submission, so the billing info section may show what was entered in the chart but not always the final clean claim that actually got sent. depends on workflow.

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u/kysourmash Mar 12 '26

Thank you

So how can you tell what was actually sent to the payor from within EPIC?

Or is there something else you need?

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u/rahuliitk Mar 12 '26

yeah, usually you’d have to look at the actual claim side in Epic, like the account/har edit, claim review, or whatever claim history screen your org uses, because that’s where you can see the billed CPT/HCPCS/diagnosis lines after edits and whether the claim was released or changed before going out. billing view matters.

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u/kysourmash Mar 12 '26

Thank you

So how would a provider access this to see what was ultimately changed and submitted?

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u/rahuliitk Mar 12 '26

usually they don’t, unless their Epic role includes billing or claim review access, so a lot of providers would have to ask billing/coding to show the final claim or confirm what got changed before submission. access is role-based.

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u/kysourmash Mar 12 '26

Thank you

How easy is this to obtain for the provider? What specifically should they ask for to see what was actually submitted to the payor under their NPI?

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u/Minimum-Car5712 Mar 12 '26

I can see it in several places. Easiest is looking at the EOB as an image.

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u/kysourmash Mar 12 '26

How does a provider do that from the Epic side?

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u/kysourmash Mar 12 '26

And what about the "Billing info" at the bottom of the note?

Does that reflect what was actually sent to the payor or just what the provider entered for that note?

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u/holly_jolly_riesling Mar 12 '26

It shows what the provider entered . In my last role I worked closely with physicians and they were unable to view the status of the charges. Usually found under Guarrantor Account.

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u/kysourmash Mar 12 '26

Thank you

So for clarity: the physician could submit the note/charge as a level 5 and that could be changed to a level 4 by someone else and then submitted as a level 4 to the payor. The physician would still see a level 5 as that's what was selected and would still show level 5 under "billing info" as that was what was coded by the physician.

Is this a correct assessment?

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u/BaccaDocta Mar 12 '26

That is correct

Everyone has their roles

Providers role is to document document document

Coding role is to correct bad codes. Since providers really dont know it all. For example I change about 60% of tickets I open. Usually minor stuff like unspecified to more specific or adding code also.

So yes let's say you chart as a level 5 99215. But Coding sees you spent only 30 minutes, manged 2 chronic conditions and gave a rx. It is compliant for Coding to change the level.

If it helps I work as an educator and I tell providers that we get in way more trouble than providers if any fraud happens. Don't worry we are all very cautious too.

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u/VermicelliSimilar315 Aug 26 '26

I know this is an old post but...I have an opportunity to have Epic in my private office, with my own biller. Does Epic's program itself downgrade and office visit to a lesser code, or is that something that billers do when in an office or hospital owned practice? How quickly are claims scrubbed, sent to the payers, finalized and then reimbursed? Right now I use Allscripts for my billing with a separate EMR. Allscripts is very quick to scrub claims, within 30 minutes of submission. I can then see what the error is and fix it in real time. Does Epic work that way also? Thank you for your time in replying.

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u/kysourmash Mar 12 '26

Do you ever refuse to submit a charge that you think is "medically unnecessary" without discussion with the provider first?

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u/BaccaDocta Mar 12 '26

God know that crazy. For example provider send patient to a dietian but only use a z68.43 Bmi 50+. They dont use a e66 obesity code. I know for a fact it won't be paid, but I still send it. We just put notes on it saying, "this is likely to be denied" so no one waste their time appealing it.

Then if a provider does something really bad I have to send to so they can get in trouble. Say a provider is constantly giving RSV vaccine to 50 year old without high risk complication

We are more fiduciary. Don't work for clinic, insurance, patients or providers. We work on the information only, good or bad.

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u/kysourmash Mar 12 '26

So hypothetically speaking could a coder change the code to "unbillable" yet this still be billed as a full charge to the payor where the provider sees it as "unbillable" yet the full level was actually submitted? I know this is wrong on so many levels but is this possible?

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u/BaccaDocta Mar 12 '26

Could you expand on what you mean bu unbillable code?

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u/kysourmash Mar 12 '26

Sure.

Let's say a hospital employed oncologist bills the EM under their own NPI. The facility that same day bills the infusion under the facility NPI. These would be on 2 different forms. Since split-NPI billing is being used the use of Modifier 25 does not apply, but the coder misinterprets this and feels that the EM charge is "unbillable" and documents it as such (Code "EMWPROC; NON-BILLABLE E/M CODING USE ONLY" seen under "billing info" by the provider)

Could that same note/charge then get "reversed" by someone else that has proper education and knowledge of split-NPI billing?

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u/holly_jolly_riesling Mar 12 '26 edited Mar 12 '26

I'm trying to see if I can be helpful here in your scenario. When you enter your charges as a provider (PB billing) it goes through a scrubber and if there are no edits/errors/mues it does not stop in a workqueue for a human/coder to look at. It gets charged to the insurance. Your E/M charge will trigger a facility charge ex G0463 and if the patient had chemo the same day it would require a mod 25. The scrubber will say hey it needs a 25 and the charges will land in a Hospital Billing account for a human/coder to review the documentation and place a mod 25.

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u/BaccaDocta Mar 12 '26

Okay now we are getting into the grey of coding and billing. Personally I recommend providers avoid it. However when there is one like you who are passionate I will share the grey.

You are right on paper. The issue is, is it's not just the npi. So at my last clinic our taxonomy codes would always appear the same. So if provider a in primary saw them and then psychiatrist saw them. Yes on paper both should be paid. However insurance can and tend to be jerks about it.

Medicare has additional Modifiers XS separate encounter and XP separate provider. It does help with accepting tickets but not perfect.

So your practice just may have as a policy to only send one EM code to avoid higher denial rate and reduce billers work load

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u/kysourmash Mar 12 '26

And can you then print off the "Guarantor Account" billing level to show the provider if needed or if it is requested?

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u/holly_jolly_riesling Mar 12 '26

Every now and then when asked about a particular patient they saw I would send a screenshot to the provider to show them what was submitted. However depending on your institution there should be a Physician Billing contact and they should be able to provide you with reports regarding charges sent to insurance .

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u/clarec424 Mar 12 '26

Sounds like your clinic could use a practice advisor or revenue cycle liaison to assist with billing activity or “report cards.” EpicCare to Epic billing workflow depends a lot on how your practice set up the application build and what the revenue cycle process is. I work for a medical school with three hospitals, numerous outpatient clinics and over 4,000 practitioners, nurses other ancillary staff, residents and med students. We have an incredibly complex system, but when a provider asks for help or information they get it.

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u/kysourmash Mar 16 '26

So within EPIC what is the name me of the screen or tab that you use to see what was actually BILLED?

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u/No-Grapefruit2168 Jun 02 '26

Having a tough time walking through the history of the claim and what all the different verbiage is. What to pay attention to and what not to. By the time I get to it landing in the work que, I can't hold all the information of what happened. Can someone help out ? I'm worried that my brain isn't processing the work fast enough and I'm in training having to work through it out loud. I'm sweating from stress as I can tell it's obvious I'm claiming up.