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AthensCoder

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Hello fellow coders,

I need some opinions from an auditors stand point regarding the below situation.

Patient presents for a screening colonoscopy. Last colonoscopy was in 2018 with the reccomendation to follow-up in 10 years. There is no family history of personal history of colon cancer or polyps. I notified the billing staff to alert the provider that the patient is not due for a colonoscopy until 2028 and query why the patient needed one sooner. The provider indicated that the patient is not having any signs or symptoms to prompt a diagnostic colonoscopy and he is doing it as a screening because "the patient has new insurance". I tried explaining to the provider from an auditors standpoint that there is no "medical necessity" to do the colonscopy earlier, and a change in insurance is not justification, as an auditor does not look at the insurance. They review the medical record. It's gotten pretty ugly between my biller and him.

Who's right in this situation.
 
I agree, this is a medical necessity question. You might remind the provider of the AMA's definition of medical necessity which is: "services or products that a prudent physician would provide to a patient for the purpose of preventing, diagnosing or treating an illness, injury, disease or its symptoms in a manner that is: in accordance with generally accepted standards of medical practice" (emphasis added). You're also correct that the medical record needs to support medical necessity or otherwise a payer may consider the service to meet the definition of a covered benefit under the patient's plan guidelines.

All that said, you also have to keep in mind that medical necessity is ultimately the provider's determination and not the coder's or the biller's, and once you've said your part you have to step back and allow the provider to practice because it's their decision and a coder isn't trained or qualified to judge that - only the provider's peers can do that. In a case as blatant this, though, you might consider submitting an ethics complaint or concern to the state licensing board, so that the peer review groups can be aware of what the provider is doing.
 
thomas7331 said:
I agree, this is a medical necessity question. You might remind the provider of the AMA's definition of medical necessity which is: "services or products that a prudent physician would provide to a patient for the purpose of preventing, diagnosing or treating an illness, injury, disease or its symptoms in a manner that is: in accordance with generally accepted standards of medical practice" (emphasis added). You're also correct that the medical record needs to support medical necessity or otherwise a payer may consider the service to meet the definition of a covered benefit under the patient's plan guidelines.

All that said, you also have to keep in mind that medical necessity is ultimately the provider's determination and not the coder's or the biller's, and once you've said your part you have to step back and allow the provider to practice because it's their decision and a coder isn't trained or qualified to judge that - only the provider's peers can do that. In a case as blatant this, though, you might consider submitting an ethics complaint or concern to the state licensing board, so that the peer review groups can be aware of what the provider is doing.
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Thank you for your response. I have reminded him of this very frequently. All the other providers will cancel the procedure until the patient is due. But this provider fights tooth and nail. It's gotten to the point where he contacted my biller when he knew I wasn't going to be in the office and pretty much threatened her job.

So are you saying to bill how the provider says because it's their decision? What's the legalities of this for the coders/billers from an auditors standpoint? We as coders/billers are told not to bill for payment and know there is NO medical necessity behind doing this sooner?
 
AmandaBriggs said:
I would remind the provider that frequency of a procedure is part of medical necessity, especially for screening services. I would also look into the payer's policies on this.
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Thank you for your response. The provider has been reminded on several occasions.
 
AthensCoder said:
Thank you for your response. I have reminded him of this very frequently. All the other providers will cancel the procedure until the patient is due. But this provider fights tooth and nail. It's gotten to the point where he contacted my biller when he knew I wasn't going to be in the office and pretty much threatened her job.

So are you saying to bill how the provider says because it's their decision? What's the legalities of this for the coders/billers from an auditors standpoint? We as coders/billers are told not to bill for payment and know there is NO medical necessity behind doing this sooner?
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I’m not an attorney, but I don’t see any legal risk to the coder or biller here because they’re not being asked to falsify or conceal any information or to submit a false claim. It’s simply a disagreement about whether or not the provider should be performing this service, which isn’t a coder responsibility.

In the organizations I've worked with, when coders or billers have had a concern like this about how a provider is practicing, it is referred to compliance and or management, and they usually refer it to the medical director to resolve. Management should advise you, hopefully in writing, how they want to handle it - to bill it or to not bill it. That's usually the end of it from a coding/billing standpoint. Management decides whether or not to take the risk and/or the financial liability, and also how to deal with the provider. It's the only coder's responsibility to raise and voice their concerns, but it's management's responsibility make an organizational decision and once they do that, then there should be no legal risk to the coder.

I'm surprised to hear you say that you are told not to bill when there is no medical necessity - who’s telling you this? Coders, most of whom don't have a clinical background or license, generally do not have the training required to determine medical necessity. While it's true that coders may review published payer policies regarding what the payers adopt for their medical necessity requirements and can advise a provider whether or not it conflicts with the provider's opinion, but a coder has no place challenging a treatment recommendation that a provider has made for their patient - it's simply not within their scope. Only another provider or peer with a physician's training can make that call. That's why a dispute like this would need to go to a medical director or peer - there's no purpose served by continuing to fight with the physician about it.

(Edited to add the first paragraph.)
 
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Just jumping on to what Thomas said, we can speak up if the medical necessity isn't supported by the documentation. For instance, if there's no mention of a condition in the problem list, hPI, hx, no abnormalities in the exam, no test results documented, and then there's CKD in the A&P. It's okay to tell the provider it's not supported by the documentation and that they need to include that or make reference to it ("new dx from nephro I agree with findings," "GFR on 1/5/23 was __.") I remind my providers that auditors usually aren't clinical so they need you to connect the dots--and in writing, because you can't go and read over the auditor's shoulder and say "what I meant was..."

If you query and they refuse to make the change, you have the query to back you up that you did your due diligence.
 
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