Can a Medical Coder change a Dx or procedure code that Dr selected

JENNIFERNMA

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Hi,


I am a CPC and wanted to ask a question to ensure compliance...Dr. codes a note (DX's and procedures) and i review the claim before going out. If i notice that a Dx or procedure needs to be changed or added and it is in line with the documentation. Am I allowed to change it on the claim without the physician ammending the note?
 

sab001

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If they pick the wrong code yes you can change it.

How would you document such a change? If I am auditing an account and identify that the coder did not use the dx code selected by the healthcare provider, I would want to see some documentation explaining the rationale for selecting something different.

Also, there should be a clear documented process in place with appropriate controls in place.

Scott Burk, MBA, CPCO
 

mitchellde

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The coder does not need to document anything. As an auditor if you saw the codes were different on the claim than what the doctor chose you would look to see if the codes on the claim match the documentation statement in the medical record. That is all that is required. Providers often select incorrect codes. A coders responsibility is to code from the rendered diagnosis provided and not not from the code provided. Also to evaluate the E&M and procedure notes and code from the appropriate criteria for that service. It really does not matter what codes the provider selects and the auditor should not concern themselves with any code numbers in the documentation as they should not really be in the document according to the AHA. So the coder needs no justification for why their codes were selected as long as they use the chart note and coding guidelines.
 

npricercm

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Hi,


I am a CPC and wanted to ask a question to ensure compliance...Dr. codes a note (DX's and procedures) and i review the claim before going out. If i notice that a Dx or procedure needs to be changed or added and it is in line with the documentation. Am I allowed to change it on the claim without the physician ammending the note?




What does your company policy state to do? We have a written policy that covers this situation. Do you have a compliance dept your can ask?
 

Pam Brooks

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In a facility setting, I would say that the coder can code exactly as the documentation reads, based on AHA and WHO guidelines and other regulatory guidance. However, if you work for a physician practice, or anywhere that physicians are compensated based on RVUs, then you would definitely want to have a policy about this.

Our physicians receive a bonus (in addition to salary) based on the number of work RVUs obtained over and above the expected threshold. This means that higher level E&Ms and/or more visits will garner them a big check at the end of the year. In instances like this, having a coder change the code that they have selected or submitted may hit their pocketbook. Now I'm the first to tell you that this is not the best way to reward physicians, but it is what it is....in many organizations. However, our organization is also extremely committed to compliance, so our policy is that the coder/auditors may change codes based on the documentation that accompanies the charge, regardless of what the provider wished to bill. If that's what you decide do, be sure to get it in writing.

Coders in small practices, or those working for physician groups without such a policy would be best to not change codes, particularly because the physician's name is on the claim form....not the coders, and there may be financial implications for the provider if you down or up-code them without their permission. But it's definitely something you should bring up for discussion--along with the risk of potential fraud, insurance take-backs, and other headaches that they might not be considering when all they worry about is their bonus check. If providers are educated properly about coding, and learn to trust their coder, in my experience, providers will leave it all up to the coder, because they just don't want to deal with it.
 
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Supervisor audited my work

My supervisor is currently auditing my work and says I have to change my code 97597 to a E/M so the provider receives a better RVU for his work. The provider's note clearly states that code 97597 was completed, and some times the provider will add the procedure code range into the patient note. So what happens if I change the service from a correct procedure code to a E/M code so my supervisor is happy with me? I think we could be setting ourselves up for a "False Claim" or a big insurance audit. Can I personally get into trouble for doing as my supervisor asks of me? I don't want to lose my job, or my AAPC credentials. We are "Huge" into compliance programs at my facility, should I report this to them? Thanks for your time. Sue
 

Pathos

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Sue Tolbert - I would report this to Compliance if I were you. Let them investigate and report back.

I agree, I see so many red flags with this. Let Compliance do their thing and I would hold off until the investigation is done. I think it goes without saying that you shouldn't bill something that isn't supported with documentation. Your supervisor might not like it, but at least you're covering your end.
 

pamela brashear

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I have a question on this I have a provider that place a dx on claim insurance has rejected claim I was asked to remove a dx code so I message the provider they refused to have this code removed now we have a billing lead who what to remove the code on front end only without removing this from the note or record. I feel this would not be correct coding as the provider did address the problem. Feel free to email me at p.brashear@hhsil.com there is not written policy on this one. I feel comfortable changing code when you do addendum however just changing on front end of claim I feel if we are audit this would be error on my part.
 
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