Wiki Coder as Biller

Create Wiki Sort by votes
B

BS&SC

Networker
Messages
33
Location
Iaeger, WV
Best answers
0
Recently landed a job as a Billing Specialist that is, for the most part, simply entering the information on the fee ticket. However, I have a hard time when the experienced biller who is training me changes a Dx code to support the payer's policy. As a CPC, I am not comfortable doing this, as I learned that it is not our job to ever change a code assigned by a physician or QHP (unless you query and they agree). I feel like I am between a rock and a hard place, being the newbie, but these charge capture entries have my name electronically associated with them and I have a certification to lose! I want to make sure something is coded correctly and not based on someone telling me to bill this code because "the payer doesn't like that code." I have tried to express my discomfort to my manager, and been advised that "we have internal auditors." Well, okay, I am not trying to be an auditor (though I can understand where a coder's mindset would feel that way to a biller), I am just trying to make sure the codes are correct and according to documentation, without regard for reimbursement.

Any advice?
 
0
I have been there.. and I have made it very clear to the person that I am working with and my team leads and HR I will not compromise my degree and certifications in anyway shape or form. I have quit jobs that have asked me to do this.. .. I would document everything and speak to your manager again and tell them what your background and degree and certifications are if they don't listen take it to HR you have to look out for your self its your lively hood and certifications on the line not theirs
 
0
I understand this would be an uncomfortable spot to be in, and I think it's a very questionable practice to allow billers (or anyone for that matter) to change a diagnosis based on a payer and not based on a review of the record.

There's a fine line here, but if you are doing as assigned, and are following a process that does not require you to knowingly falsify information, and have made your concerns known to the manager or compliance officer and have been given assurance that the provider has measures in place to ensure the quality of their claims, then it's highly unlikely you are putting your credentials in jeopardy or are putting yourself at a compliance risk. It's a good idea to document any of your conversations with your managers and or trainers so you'll have a record just in case you were every questioned about it, (which I think would be pretty unlikely) but I wouldn't be overly anxious about it.

I would recommend a little more caution if you actually know that the provider is falsifying the records - i.e. if you are reviewing and coding the records and know what the correct codes are but are still being told you have to change them to incorrect codes to get payment and are required to do this repeatedly on a substantial number of claims - that could be considered participating in actual fraud. In that situation I'd likely be seeking employment elsewhere and depending on the severity of it, would potentially consider reporting this provider to the payers and/or legal authorities.
 
0
BS&SC said:
Recently landed a job as a Billing Specialist that is, for the most part, simply entering the information on the fee ticket. However, I have a hard time when the experienced biller who is training me changes a Dx code to support the payer's policy. As a CPC, I am not comfortable doing this, as I learned that it is not our job to ever change a code assigned by a physician or QHP (unless you query and they agree). I feel like I am between a rock and a hard place, being the newbie, but these charge capture entries have my name electronically associated with them and I have a certification to lose! I want to make sure something is coded correctly and not based on someone telling me to bill this code because "the payer doesn't like that code." I have tried to express my discomfort to my manager, and been advised that "we have internal auditors." Well, okay, I am not trying to be an auditor (though I can understand where a coder's mindset would feel that way to a biller), I am just trying to make sure the codes are correct and according to documentation, without regard for reimbursement.

Any advice?
Click to expand...
Are you asked to use a Dx code that is not documented by MD? Can you give an example?
 
0
There is a fine line, and whether or not a biller can change a dx code depends largely on internal company policy ASSUMING the diagnosis code assigned is supported by the medical records.

Let's say you have a payor that does not like unspecified codes. The physician assigns dx R10.9, abdominal pain unspecified. Records clearly indicate the abdominal pain is in the right lower quadrant. Changing R10.9 to R10.31 is actually correcting the code. Whether this correction may be made by a biller, a certified coder, or only by the physician is up to internal company policy.
What a coder (or biller, or physician for that matter) may not do is assign a code that is not supported by the records. If a physician orders a CT abdomen, you may not assign abdominal pain if it's not in the records. To do so specifically for the intent to get paid is where you definitely run afoul of compliance.

If your company is asking you to assign codes that are not supported by medical records, and management does not seem to care, I would look for a new job.
If your company is asking you to see if there's a better diagnosis code supported in the record because physicians aren't always great coders, then to me, that is exactly the job of a coder (or biller depending on the company).
I've worked with many amazing clinicians who have a tendency to type a word or two in the EHR system and then pick whatever code is at the top of the list. Or assign codes that are should never be coded together. In my organization, only a certified coder may correct the codes without query to the physician.
 
0
Thank you all for your replies! I appreciate the guidance as I try and figure out my "place" in this new job. I have realized that our "encoder," which is part of the NextGen product, is where physicians choose their codes and where our third party billing office generates its "warnings" when we scrub a claim. Not 100% on this, but I do know they do not use and Encoder just for billers/coders other than what is in NextGen--and we don't have access to whatever this "encoder" is.

In the billing office, and as an example, yesterday I received a blue edit saying the diagnosis was not acceptable to the payer, it then suggested some codes. These codes, however, were not in the EHR Assessment and Plan (so undocumented). This is where I have to pause and consider what to do which, to me, translates to not changing the code. The code, if I remember correctly, was O99.213 (Obesity complicating pregnancy, third trimester). While I know I can change a O99.219 to specify trimester, I don't feel comfortable changing this code if no other code is documented in the physician's Assessment/Plan. But why does the scrubber even suggest these then? Is this, again, back to me asking, as a CPC, what internal policy is on who can change codes?
 
0
BS&SC said:
Thank you all for your replies! I appreciate the guidance as I try and figure out my "place" in this new job. I have realized that our "encoder," which is part of the NextGen product, is where physicians choose their codes and where our third party billing office generates its "warnings" when we scrub a claim. Not 100% on this, but I do know they do not use and Encoder just for billers/coders other than what is in NextGen--and we don't have access to whatever this "encoder" is.

In the billing office, and as an example, yesterday I received a blue edit saying the diagnosis was not acceptable to the payer, it then suggested some codes. These codes, however, were not in the EHR Assessment and Plan (so undocumented). This is where I have to pause and consider what to do which, to me, translates to not changing the code. The code, if I remember correctly, was O99.213 (Obesity complicating pregnancy, third trimester). While I know I can change a O99.219 to specify trimester, I don't feel comfortable changing this code if no other code is documented in the physician's Assessment/Plan. But why does the scrubber even suggest these then? Is this, again, back to me asking, as a CPC, what internal policy is on who can change codes?
Click to expand...
If you are talking about blue and red edits in NextGen, those can either be internal edits or NextGen edits in the claim scrubber. Many of those are manually entered by the practice and may or may not be correct. If the edit engine has not been maintained or updated properly it could be suggesting the wrong thing. Those are just "suggestions" in the description of the edit. It is only a suggestion, it can't take the place of a person. Blue edits sometimes need to be bypassed if you reviewed it and made a coding decision manually. NextGen also has edits that are maintained at a product level and updated regularly.

You are correct, you need to better understand what your role is and what you are being expected to do as your job duties. Thomas and Christine are giving you good advice above.
Are you supposed to only clean up demographic errors, are you actually expected to "code" manually, are you cleaning up modifiers only? Are you instructed to refer the claim to a coder if it has red edits?
 
You must log in or register to reply here.
Top