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davehudgb

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Scenario: I've been asked to create some general rules for Claims Data Entry Individuals to select codes from the Provider's office super bill. The physician is selecting all codes for the encounter. There system generates a Superbill with ALL ICD 10 codes linked to each CPT Code. I've been asked to create guidelines to associated the ICD 10 to the CPT for the data entry processor. Medicare / MCO denied 17110 due to the present selection / allocation of ICD 10 to CPT.

Example:

ICD-10’s: 1) M20.11 2)M20.12 3)M24.575 4)M24.574 5) M20.41 6) M20.42 7) D23.71 8) Z68.1 9) M79.671 10) M79.672

CPT: 17110 ICD -10 Code Association: 1,2,3,4,5,6,7,8,9,10

I've been told this is not coding only diagnosis selection for the claim.

Is it me or does this not seem problematic?
 
I'm not sure I'm understanding your question. In your case, the physician is selecting the codes. If the physician has a procedure that requires a diagnosis code that is not included in what they selected, you can query the provider. For instance, for trigger point injections, Medicare will only cover a handful of diagnoses. If your provider does trigger points and does not include one of those diagnoses, you can query the provider. Almost all of our patients have fibromyalgia, which is a covered dx for Medicare for Trigger points (for my jurisdiction). The patient may have so many dx that fibromyalgia doesn't make it to the claim. I know I have to resolve that before I can send the claim.
 
This is a podiatry physician - This is in his encounter ICD 10's and superbill info as shown below:

Example:

ICD-10’s: 1) M20.11 2)M20.12 3)M24.575 4)M24.574 5) M20.41 6) M20.42 7) D23.71 8) Z68.1 9) M79.671 10) M79.672

CPT: 17110 ICD -10 Code Association: 1,2,3,4,5,6,7,8,9,10
CPT: 99213 ICD - 10 Code Association: 1,2,3,4,5,6,7,8,9,10

As you can see he as selected ALL codes for both CPT's. The code selection which occurs on several claims for 17110 are denied by Medicare as they do not meet the criteria for medical necessity.


The physician stated he is selecting all the appropriate codes for his encounter. He is NOT designating them to each CPT Code - he associates ALL of them to each cpt. They do not have an internal coder at that physician office. I'm being asked as a billing agency employee to right up directions / guidelines to associate each diagnosis to the cpt code. Essentially saying that if 17110 is being billed select D23.71 Primary, M79.671 and M79.672 secondary, Bill 99213 will All ICD 10 presented. Then the data entry clerk will input based on that information. There is no querying of the physician. I was told this is not coding but claim ICD 10 selection (Not sure what that means).

So if I generalize the situation - The physician is randomly selecting his codes that apply to the visit, in no specific order. Generates a superbill and sends it to us for processing. I'm suppose to write procedures to take what he's billing and associate the ICD 10's to the CPT's for the data entry clerks to input in the billing software to bill. The claim gets billed.


Essentially take his Superbill, use a rule or guideline that I write up, associate the CPT with the ICD 10 and bill the charges.

This is not a responsible way to "code" claims is what I'm attempting to validate. I explain this shouldn't be done by our agency like this, it irresponsible, and I was asked to continue to write up guidelines.
 
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It should not be up to you, as the 3rd party biller, to properly associate which problem goes with which procedure code. I'm guessing you don't have access to the medical record for the date of service. Just because a diagnosis is "in the list" doesn't mean it's why the provider performed a procedure and you would be making dangerous assumptions. If something goes wrong and the bills get audited and payments recouped, who do you think will take the blame? The provider should either be doing this himself or have a staff member making sure the Superbill has the correct linking before it is submitted to you for charge entry and billing.

ETA clarification
 
Thank you for validating my concerns. That was my standing on the situation, that in fact the provider should be associating his ICD 10's to his procedures and if not have a coder of some degree within his office to facilitate and oversee this function. The should be sending the claim with the correct appropriate association. We do in fact have access to the EMR, however, this appears to be a situation we are attempting to accommodated. I will keep my opinion to myself

T
 
Back when dinosaurs roamed the earth, I worked as a coder for a 3rd party billing company. If the physician's office contracted with us for coding services, then absolutely I was responsible for assigning ICD codes and linking them to the correct procedures but I also had the medical records to do so. Not all providers we billed for used our coding services and those offices had to send their charge sheets to us exactly as they wanted it entered in the system for billing.

If possible, try to look at the language in the contract you have with the providers. It should specifically spell out what you (the billing co) is responsible for vs. the physician based on the purchased services.
 
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