Wiki code corrections and modifiers

cwater

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Ultimately the physician is responsible for codes, modifiers and diagnosis that are submitted on a claim.

I am looking for information on what a certified coder can do vs. a non certified medical biller.
Can a medical biller who is not certified add a modifier to a claim or must this be done by a certified coder?
Can a medical biller without certification update information on a claim or must it be a certified coder and what documentation is required to be kept on file?

Any information about the support staff for the provider relating to medical billing in the Pennsylvania regarding what the support person is able to do if they are certified vs. non certified would be appreciated.

Thanks,
Camille Waterhouse, CPC
 
Certified vs. non-certified

Camille,

I'm not aware of any regulation that says modifiers must be added by only certified coders. There are probably 20-25 non-certified coders performing coding and billing function in my town alone of 50,00-60,000 population. I would say 5-10% of the charges submitted in my town are done with certified coder involvement and the remaining 90-95% is submitted by non-certified coders. There are not many certified coders in my town and I would assume that is quite common across the country. If only certified coders could update claims and/or add modifiers then I'm pretty sure there would not be enough certified coders to do the work and many practices would have to close.

I think the bigger questions/issues are: Does the coder/biller, whether certified coder or not certified: 1) have the knowledge and background to perform their job accurately and most importantly 2) have the backbone to stand up to the clinician (whether MD, PA, NP, or whatever) when the clinician is wrong in what/how they are wanting billing to be performed and refuse to back down when they are confident the clinician is wrong.

I had a conversation with a certified coder that was paid by a physician to review coding prior to being sent to insurance. I became aware of ongoing, severe coding errors that were being made and not corrected. I had a conversation with the CPC and she stated, and I quote "The doctor knows everything, who am I to question the doctor?" I then asked her if the doctor was a certified coder and she said no. I then asked her if she never intended to correct his coding mistakes then what was he paying her for? The conversation abruptly ended. Go figure. So, my issue is - do the right thing and do not be afraid to tell the clinician "you went to medical school and I don't tell you how to treat patients, I'm trained/certified in medical billing so don't tell me how to do my job." For certified coders and the profession to have any integrity we must acknowledge we know more about coding and billing than 99.9% of clinicians and to be confident to stand up when we see something wrong vs. allow it to continue because "this person signs my paycheck."

Hunter Smith, CPC
 
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