Wiki Downcoding - I know that


Perkasie, PA
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I know that when I audit records and the doctor has upcoded the charge that we are obligated to return any overpayment. If a doctor downcodes, should we make the billing correction for the higher code.

In the future all audits will be pre-pay, but the current audits are being done to establish a baseline. So, in order to review a large enough sampling it is easier to pull from post pay records, due to how our billing system works. So, I have to deal with these overpayments, etc.
We do not re-bill for higher code

We do not re-bill for the higher, documented, code after an audit. We DO refund any monties collected when we find that a lower level code was documented.

We also give each physician a spreadsheet analysis showing the difference in payment for correct coding vs incorrect coding ... this clearly shows monies returned, but also shows missed revenue for downcoding.

No matter how you look at it, incorrect coding costs the practice money.

Hope that helps.

F Tessa Bartels, CPC, CEMC
Thanks Tessa. That is what I thought. I never thought of including in my analysis the difference in revenue. That may be a good addition going forward. I bet our CFO will ask me for it in the future.
Bill missed charges?

Tessa: Would you bill for missed charges (other than an E&M) caught during her audit, such as an in-office procedure, injection or x-ray?
When I have found charges that the previous coder missed I have coded them to the chart but with a 0 dollar amount. This way they are documented but neither the patient or their insurance is charged for them since it was an office oversight/error.
Missed charges discovered on audit

Yes, we do bill for charges we have previously missed (whether discovered via audit or any other method) ... of course this assume we're still within timely filing guidelines.

Hope that helps.

F Tessa Bartels, CPC, CEMC
down coding

I was wondering on your reply Teresa, I was under the impression we could not down code a rad chart when it was missing elements, just to get paid??? Is this misinformation ?
Martha, what about when a CTA is ordered but there is no mention of reconstructions or MIP to support the CTA in my old practice we would down code to a CT