Wiki Physicians Not Specific Enough

[CarlyMae]

Hi Everyone, first time posting, so hopefully this is the proper thread!

I work for a company that does billing, coding and collections for outpatient surgery centers (ASC). We are increasingly running into problems where our coding of operative reports does not match up with how the surgeon's office codes their professional claims. The surgery center administrators get frustrated when our codes don't pay as much as they expected (based on what the doctor said he would perform). It is our policy to code only what is documented, so we then have to ask physicians to re-dictate or add an addendum to their operative report, stating that they actually performed the service that they so adamantly claim they did (and billed for!).
We run into this issue for services ranging from pain injections to full joint replacements. We have to explain to administrators, physicians and even patients that we can only bill for what is dictated in the body of the operative report. Yet we are getting more and more push back and or flat out refusals to re-dictate, leaving us with either a low or non-paying CPT, unless we 'take their word' that the service they claim was actually performed.
Has anyone experienced this and had success in explaining to physicians why it is so important that they dictate exactly what was done? Short of providing them a template of common surgery dictations, how can we get them to be more specific?

**I'm not asking about specific cases because this is an issue we experience for all kinds of procedures. I am looking for a better way to explain to a physician why it's so important that they are specific in their reports. Better yet would be some kind of 'official' documentation that explains why they should be doing it, as obviously billing what isn't documented leaves them open to audits and refunds!**

 

[mitchellde]

First you cannot hav a note re dictated or amended after a denial or underpayment is received.
What you can do is request the payer audit the physician claim since they were paid based on different coding for the same service. Yes your codes should match but yes all coding is to based on the dictated note, not what they intended to perform, or that they did it but failed to state it. You can only code that which is documented. If that fails to pay or is reduced in payment from what is expected, you can only appeal with the documentation you had at the time of coding. You cannot now bring in new or additional information to resubmit the claim.

 

[CarlyMae]

First you cannot hav a note re dictated or amended after a denial or underpayment is received.

Can you show me where that is from? In the 10+ years we've worked with ASCs, we have never found anything that states that physicians can't addend their reports. They are not completely re-dictating the reports.

But to further explain; we aren't billing insurance, getting a denial and THEN going back to the doctor to ask for more information. We receive the report, code it, see that it doesn't match what the doctor told us he was going to do, so we call his office to check how they coded. Their offices often don't want to deal with adding an addendum because they were paid just fine, but I would guess that's because their claims aren't being reviewed with the operative report. We work with 15 surgery centers across all specialties and this issue pops up at each of them. This isn't a "every claim we do" issue, but happens often enough that it's frustrating to our staff to constantly have to defend ourselves and our coding.

So back to my original question: does anyone have documentation or a good resource to use to show physicians that 1) we can legally only code what is documented in the operative report, so therefore 2) they need to be as specific as possible in their documentation of every single procedure performed.