Wiki Please help!! In a pickle

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hduscio789

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I work at a surgery center and our coders have coded 0335T based on what the OP report states and supports. It is not paid by government plans because it's experimental so we are getting denials for it. We have told the doctor this and he insists that we should bill it as "28585" instead. I guess he has spoken to an attorney and said it was okay to bill that way. That just seems weird to me. What would an attorney know in regards to coding and fraud? So now my boss wants me to bill 28285 because it is payable even though our coders don't agree. I don't want to commit fraud or use a code just to get paid. That puts me at risk.

What do I do? Is there a reason why the doctor's OP report doesn't support 28585?
 
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Without seeing the patients chart, it's hard to say. I would ask him why he feels that code is correct and if he could point out where in the chart it's supported. If he just says, "Because the insurance company will pay," then obviously that's a problem and you could try explaining that the code has to be fully supported in medical documentation. In my experience, a lot of times doctors don't understand the point of codes and just want to do whatever benefits them the most. It just happened to me at work last week; they wanted me to use a completely irrelevant diagnosis code to get around the denial. Trust your gut reaction. It's probably helpful that everyone else there is in agreement with you. Good luck!!!
 
kbrasington said:
Without seeing the patients chart, it's hard to say. I would ask him why he feels that code is correct and if he could point out where in the chart it's supported. If he just says, "Because the insurance company will pay," then obviously that's a problem and you could try explaining that the code has to be fully supported in medical documentation. In my experience, a lot of times doctors don't understand the point of codes and just want to do whatever benefits them the most. It just happened to me at work last week; they wanted me to use a completely irrelevant diagnosis code to get around the denial. Trust your gut reaction. It's probably helpful that everyone else there is in agreement with you. Good luck!!!
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Thank you. I'm just going to pull up the LCD/NCD and see what he needs to say in his OP report if he wants to use that CPT code. Either way, I'm not going against what the coders say to code! No thanks!

Thanks for your comment/advice :)
 
No problem! Let us know what happens. I always tell myself that every code and modifier must be supported somewhere in the documentation. You could always try mentioning that it may be fraudulent. Sometimes saying the five-letter F word is enough to make physicians listen ;)
 
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