Wiki Coding disagreement with a provider

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Metroderm

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I often have an argument with my provider about the codes. For example, she wants to bill CPT 96402 for humira injection with Office visit and I disagree.
I explained that this code is for the IV injection and give her the description of the code, but she still insists.
Most of time I just follow provider's direction and wait for the denial.
Sometimes the claim gets paid as is (with a wrong code) and she feels that she was correct.
I'm sure you all have this type of disagreement and I would like to know how you deal with the situation.
What do you do when you can't make them understand to the correct code?
Also what could be the consequences for me if we are audited?
 
I agree with Sharon. If it is a black & white issue and the physician is unwilling to listen after you explain, I would not want to work for that physician.
Getting paid is not an indication that you coded correctly. I have been fortunate enough to work with physicians who will clarify the service they provided, and allow me to do my job.
Regarding audits - it can depend on who is auditing you and whether they did a random audit of one claim, or whether they are requesting multiple records. Sometimes they may just not pay (or request a refund if already paid) on a specific claim. If the carrier does a more comprehensive audit (say 20 claims with 96402) and they determine that 100% of the time, you coded wrong, they may ask for payment back on EVERY 96402, not just the 20 audited claims. They could even terminate your contract or cause legal issues depending on the level it is raised to.
Basically, just like with the IRS, and audit in and of itself is never fun, but not always a problem. Unless you know you are coding incorrectly, which is fraud. I would not take that risk. Either figure out a way to educate the physician that she will listen or start a job search.
 
I totally agree with Sharon & Christine. If you have done your due diligence and can't get the provider to bill correctly, you need to move on. Something that you could try is to document in the computer on every single one of these that you disagree with the coding and are billing the providers codes. That may get someone's attention as well. Our company brought in outside auditors because they wanted to know what their "exposure to risk" was as far as inaccurate coding and billing. At the end of the audit they were shown that they had a "very high' risk of audit and all the problems that it brings. I was given 100% control over the codes after the audit, and we have been passing our audits ever since.
 
Orthocoderpgu said:
I totally agree with Sharon & Christine. If you have done your due diligence and can't get the provider to bill correctly, you need to move on. Something that you could try is to document in the computer on every single one of these that you disagree with the coding and are billing the providers codes. That may get someone's attention as well. Our company brought in outside auditors because they wanted to know what their "exposure to risk" was as far as inaccurate coding and billing. At the end of the audit they were shown that they had a "very high' risk of audit and all the problems that it brings. I was given 100% control over the codes after the audit, and we have been passing our audits ever since.
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Bring this up to your compliance officer. Your company passes audits when you are the one coding, not the physician. If they have this evidence they may help you in conveying to your physician that you know what you're talking about.
 
Thank you so much everyone for the advise. We're a group practice and this one provider is always giving me a hard time. I will definitely bring this to the compliance officer and will see what can be done.
 
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