Who Has the CPT® Code Final Say?

Who Has the CPT® Code Final Say?

Find out if code selection ends with the coding professional or the provider.

Q: Our facility is having a heated debate about who should have the final say on the CPT® code submitted for billing: the provider or the coder?

The providers’ argument is that they should have the final say since it’s their National Provider Identifier (NPI) number listed on the claim, and if the billing is wrong, they are personally liable.

The facility says coders should have the final say, since they are the coding experts, and although the providers’ NPI is listed, the facility is ultimately responsible for billing compliantly. The facility reasons the coder is the individual who reviews the documentation and determines which code best applies to the documentation.

Please provide direction on who would be held accountable for billing issues at a provider-based billing facility. 

A: There isn’t a black and white answer to your question.

On one hand, you could argue that the provider makes the final decision. After all, the provider is the one who enrolled in the program and whose NPI forms the basis for the claim. On the other hand, the coding professional is the one with the skill set to correctly apply codes based upon the documentation the provider presents.

In the course of providing care, much of the cognitive information obtained by the physician fails to get reduced to writing, and the physician’s perception may be that the situation was more acute than reflected in the documentation. When encountering such a situation, the coder should seek additional documentation. If none is received, the coder should make the provider aware of the documentation guidelines that apply to the claim in question. The claim should go out the door as an accurate representation of the provided service.

Legally, the provider is responsible for any claims not supported by correct codes and documentation; however, part of a coder’s job is to ensure coding accuracy.

Perhaps, through collaboration, the parties can work toward a process that will result in both the coder and the provider agreeing on the appropriate code. Communication and education can resolve most disputes.


 

Robert A. Pelaia, Esq., CPC, CPCO, is senior university counsel for health affairs at the University of Florida College of Medicine, Jacksonville, Fla. He is certified as a Healthcare Law Specialist by the Florida Bar Board of Legal Specialization and Education, serves on AAPC’s Legal Advisory Board, and was a 2009-2011 AAPC National Advisory Board member. Pelaia is a member of the Jacksonville River City, Fla., local chapter.

Julie E. Chicoine, Esq., RN, CPC, CPCO, is senior attorney for Ohio State University Wexner Medical Center. She earned her Juris Doctor degree from the University of Houston Law Center. Chicoine also holds a Bachelor of Science and nursing degrees from the University of Texas Health Sciences Center at Houston. She writes and speaks widely on healthcare issues, and is an active member of the AAPC community and the Columbus, Ohio, local chapter.

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