Question Coding outside the required cpt and icd guidelines

SR2020

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I am working on a team in which you are not expected to question your superiors.
So I code to guidelines specifications - adhere to my exclude 1 rules; code to specificity; avoid unbundling etc etc but then there is your leader who tells the team - no we will use this code for all this particular cpt or we will use this cpt because it reimburses more or let us unbundle and there I am in the middle of job jeopardy and explaining that's not appropriate and or risk being marginalized.

If you have experienced this please let me know what approach you have used.
 

Orthocoderpgu

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I was actually in your exact situation when I first started. I was not only not allowed to change the codes the physicians chose, but I was never allowed to even look at the documentation! Because of that we were constantly billing incorrect charges on patient's since the front office girls did not pay attention when making appointments and they scheduled the appointments on patient's with similar names. This lead to a lot of problems. Administration wondered why I was not catching these issues during the coding process since the notes and charges would not match. So one day me and my supervisor had to go to administration to answer for all of our incorrect work. I was being grilled by five people in administration. When they found out that I was not allowed to even look at the documentation you could hear the audible gasp from several people all over the room. I was told to go back and code with the charts and verify that everything was properly documented. When I did that I noticed that all of the physicians were over coding EVERY E/M. My supervisor who thought it was no big deal to code without ever looking at the charts was now telling me that it was not my problem and that the physicians were responsible for the codes, not me. My supervisor was never a coder and did not realize that coders are also responsible. Since I could not get through to my supervisor that the codes were not supported I started looking for other employment. While I started my job search the company hired an outside coding company to audit the codes. Guess what? Every physician failed their audit! The auditing company let us know that if we did not comply to correct coding rules that we could get in serious legal trouble since almost none of the E/M codes were supported by documentation. I was given 100% control over the codes being billed, and I was expected to follow all coding guidelines. I usually passed my audits with 95% or better. I'm still with the same company after several years, but they learned that not following the guidelines can get them into trouble that they don't want. My advice. Speak to your supervisors and write down the date, time and what was discussed. If they are not open to following guidelines, then look for other employment.
 

SR2020

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I was actually in your exact situation when I first started. I was not only not allowed to change the codes the physicians chose, but I was never allowed to even look at the documentation! Because of that we were constantly billing incorrect charges on patient's since the front office girls did not pay attention when making appointments and they scheduled the appointments on patient's with similar names. This lead to a lot of problems. Administration wondered why I was not catching these issues during the coding process since the notes and charges would not match. So one day me and my supervisor had to go to administration to answer for all of our incorrect work. I was being grilled by five people in administration. When they found out that I was not allowed to even look at the documentation you could hear the audible gasp from several people all over the room. I was told to go back and code with the charts and verify that everything was properly documented. When I did that I noticed that all of the physicians were over coding EVERY E/M. My supervisor who thought it was no big deal to code without ever looking at the charts was now telling me that it was not my problem and that the physicians were responsible for the codes, not me. My supervisor was never a coder and did not realize that coders are also responsible. Since I could not get through to my supervisor that the codes were not supported I started looking for other employment. While I started my job search the company hired an outside coding company to audit the codes. Guess what? Every physician failed their audit! The auditing company let us know that if we did not comply to correct coding rules that we could get in serious legal trouble since almost none of the E/M codes were supported by documentation. I was given 100% control over the codes being billed, and I was expected to follow all coding guidelines. I usually passed my audits with 95% or better. I'm still with the same company after several years, but they learned that not following the guidelines can get them into trouble that they don't want. My advice. Speak to your supervisors and write down the date, time and what was discussed. If they are not open to following guidelines, then look for other employment.
 

SR2020

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Thank you for sharing your story. I really appreciate the feedback also happy that you had a positive outcome.
 

kdlberg

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Yes, if the doctor chooses the wrong code or overcodes or unbundles, then they are responsible for that. But if you let the mistake continue on through the process, you are also responsible, because as a coder, you know what the guidelines are and are "choosing" not to follow them.

I put choosing in quotations here, because I see that you want to do it correctly. But your supervisor is pressuring you to commit fraud. Are they worth paying thousands of dollars in fines? Or even jail?

Document every instance you have tried to educate them, every time you've been told to unbundle or change a code to get a higher reimbursement. And get out of there ASAP. Good luck.
 
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