Don’t Change the Code

Take a stand when patients are told you can code differently.

By Pam Brooks, CPC, PCS

I was very interested to read the article, “Just Change the Code” by Simone Tessitore, CPC, COBGC, in the May 2010 Coding Edge.

Our facility owns multiple primary and specialty care practices, and recently this issue has come to the forefront after several of our practice managers and customer service staff reported patients were calling with angry demands to change codes. When we learned patients had been told by the payers that claims will be paid only if they are coded in a certain or different way, we knew we had to take a stand.

Inform Patients

First, we met with the president of our local medical management association. We asked him to bring this concern to their next meeting and address it with the third-party representatives who also attend these meetings. At the meeting, the association requested that payers caution their customer service representatives to not suggest to patients that a claim was denied due to the way it was coded, or insinuate that a physician’s office simply could make a change in the code sets to satisfy coverage limitations because, in doing so, they were potentially requesting we commit fraud.

Second, we drafted a disclaimer to present to our patients prior to their receiving services. Essentially, the disclaimer reads:

Patients are expected to sign this disclaimer annually with hope of educating them regarding our commitment to compliance, and to protect us from any potential improper billing. For Medicare recipients, this disclaimer is also presented with an Advance Beneficiary Notice (ABN), if appropriate.

Review Claim Denials

Errors occasionally are made with the selection of ICD-9-CM or CPT® codes, particularly in the electronic medical record (EMR) world, where physicians often submit these choices without a pre-billing audit. All patient requests for claim denial review should be performed by a certified coder to determine if an administrative error was made, or if a claim was denied for coverage reasons.

If an error is identified, the original documentation must always support the correct code, and it should be noted the corrected claim was resubmitted due to an administrative error—not specifically to meet a payer’s specific coverage guidelines. Appending a record to support an additional diagnosis exclusively for payment reasons is inappropriate, but additions may be made to clarify a legitimate ICD-9-CM or CPT® issue.

Discourage physicians from submitting or changing codes specifically to meet the demands of patients. It is our responsibility as certified coders to educate our physicians on this risky practice.

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John Verhovshek

John Verhovshek

John Verhovshek, MA, CPC, is Managing Editor at AAPC. He has covered medical coding and billing, healthcare policy, and the business of medicine since 1999. He is an alumnus of York College of Pennsylvania and Clemson University, and a member of the Asheville-Hendersonville AAPC Local Chapter.
John Verhovshek

About Has 402 Posts

John Verhovshek, MA, CPC, is Managing Editor at AAPC. He has covered medical coding and billing, healthcare policy, and the business of medicine since 1999. He is an alumnus of York College of Pennsylvania and Clemson University, and a member of the Asheville-Hendersonville AAPC Local Chapter.

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