debellis59
Networker
Hi Everyone:
I'm not sure if this is the right forum for this, but nothing else seemed to quite fit. Our employer has recently made the decision to Auto Drop claims for our providers who they claim meet coding accuracy that allows this. They state that 80% of providers industry wide are able to auto drop claims without coder review. They will not provide us with where they come up with this "industry standard" that states this. In addition, the "coding" that they are going by is for CPT only and does not include HCPCS, ICD-10, modifiers, etc. So long as the provider has not had one of us change too many CPT codes, they feel they can auto drop the claims. However, SO MANY have come back already because of missing modifiers, incorrect diagnosis order, etc, but they state we can just work them on the back end when they are denied. For example, we have providers selecting 20605 for knee injections, not using a modifier ... so these are being denied, but still we get nowhere in this argument.
I am the ONLY one of the coders that had my arguments approved against my providers being able to auto drop their claims. I do OBGYN, MFM, Newborns, Lactation, PreOp services and was able to successfully argue that these services are unique and why. However, not one single other specialty, nor the FP/IM services, have been able to fight this. Even though providers don't remember modifiers for additional services, laterality, etc., sometimes selecting incorrect procedure codes altogether, they want to continue with this. Even the cardiac coders are unsuccessful in fighting this mess. In addition, one of the directors in the past has tried to tell my coworker and me that we can always work claims when they come back and tried to push us to not even read the chart notes ... I changed jobs because of her, but here she is again! Yes, the same company, different location.
Is there an "Industry standard" for this? And if so, where can I find this information? I can't imagine that any "industry standards" for an auto drop of provider claims would only be for CPT coding and not take into account diagnoses, modifiers, procedures, etc.
Any help someone can provide would be extremely helpful.
Thank you!
I'm not sure if this is the right forum for this, but nothing else seemed to quite fit. Our employer has recently made the decision to Auto Drop claims for our providers who they claim meet coding accuracy that allows this. They state that 80% of providers industry wide are able to auto drop claims without coder review. They will not provide us with where they come up with this "industry standard" that states this. In addition, the "coding" that they are going by is for CPT only and does not include HCPCS, ICD-10, modifiers, etc. So long as the provider has not had one of us change too many CPT codes, they feel they can auto drop the claims. However, SO MANY have come back already because of missing modifiers, incorrect diagnosis order, etc, but they state we can just work them on the back end when they are denied. For example, we have providers selecting 20605 for knee injections, not using a modifier ... so these are being denied, but still we get nowhere in this argument.
I am the ONLY one of the coders that had my arguments approved against my providers being able to auto drop their claims. I do OBGYN, MFM, Newborns, Lactation, PreOp services and was able to successfully argue that these services are unique and why. However, not one single other specialty, nor the FP/IM services, have been able to fight this. Even though providers don't remember modifiers for additional services, laterality, etc., sometimes selecting incorrect procedure codes altogether, they want to continue with this. Even the cardiac coders are unsuccessful in fighting this mess. In addition, one of the directors in the past has tried to tell my coworker and me that we can always work claims when they come back and tried to push us to not even read the chart notes ... I changed jobs because of her, but here she is again! Yes, the same company, different location.
Is there an "Industry standard" for this? And if so, where can I find this information? I can't imagine that any "industry standards" for an auto drop of provider claims would only be for CPT coding and not take into account diagnoses, modifiers, procedures, etc.
Any help someone can provide would be extremely helpful.
Thank you!
