Wiki Proper and consistent coding

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lillianivy

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I need help. I am the primary coder in our office and have been the only one for the longest time. We have recently increased our services, therefore, have hired a part-time coder to help when needed. We have set policies and procedures. The new coder refuses to comply. She has been coding for years and set in her ways. And due to certain personal circumstances she cannot be let go. I have informed her the importance it is to be consistent and the fact that we follow NCCI coding edit/CPT/ICD-9/HCPCS guidelines. I have spoken with my supervisor and have been told since I am the Main Coder it is my responsibility to inform her and have her comply. Yet, no authority to discipline.

One of the issues is the order of the CPT codes. We can have up to 20 or more CPT codes on one claim. If you plug in all codes in a NCCI edit tool it list the codes in a certain order. Therefore, we have been listing them in the proper order when billing. And have been for years. She refuses to comply with this and argues that it doesn't matter. Is there any document out there that can state the importance of proper order of CPT code billing. I've been taught in school that this is the proper protocol, plus when studying for the exam before I took it, it was clear that the codes needed to be in a certain order. Same goes with DX. Which all facilities have there own policies they comply to. Previous coding jobs I have had the same policy that had to be applied.

There are other policies that she also does not comply with, that relate to our facility's personal policies. We put certain data in line 19 and have been for years. Certain insurance's will pay for some services and some do not, therefore I bill for those services. She refuses to bill for those services at all. Claiming it's not necessary. My thinking is every insurance policy is different and if they pay for that service then you bill for it. Plus we are loosing money when she refuses to bill for it.

I guess my main concern is with this inconsistent coding, could this possibly lead to attention from all insurance companies. I definitely don't want to draw attention to us to cause an audit. Is there any articles or information that can help support my case. Or tell me that CPT codes being billed in a certain order does not matter. It would be nice to have in writing Guidelines/Articles that support my argument and to support our facilities personal policies being followed.

Thank you!!!
 
I have a number of thoughts. Have a seat....

You seem to be getting mixed messages. The very first thing I would do is to go over your job description with your supervisor. I am very sure it says nothing about you having to do any supervising. I'd get that cleared up right away. Then you can propose they change your job to include a supervisory role (complete with the ability to coach, warn or discipline as appropriate). Think about it.... It sounds like you're being asked to do the dirty work. Oh, and if you're supervising staff you should get a raise. Otherwise, the other coders' mis-coding is their problem, not yours. Don't cave in on this, because they are taking advantage of you. If they refuse, simply document what you've uncovered so far, point out the compliance issues and step away. You've done your due diligence.

I am not sure what kind of personal circumstances would prevent anyone from getting fired. Keeping someone who is clearly inept, regardless of the situation is bad business. Coding isn't something that you can do 'sort of' correctly. It has to be correct all of the time. And her inability to learn new things means that this person is a risk to the organization. Again, that's still their problem, not yours, until you are given the ability to do something about it.

If you have written policies and procedures, then there is no reason for them to be ignored. An in-house audit can turn up all sorts of regulatory issues and contradictions that you can then use to illustrate this person's inability to follow coding guidelines. Offer to do an independent audit of her work, bring them the results, use regulatory guidance and coding conventions to support it, be sure to keep it professional and leave your personal feelings out of it, and then let it go. If your supervisor chooses to do nothing about this circumstance, then there's nothing you can do, either.

If you have done all you can do with what limited power and ability you have within this organization, and you are still uncomfortable with this person's coding ability and the mistakes they make, then it might be a good time to think about leaving. Because if she's as dangerous as you say, and your management isn't going to do anything about it, then it's not a very good place to work.

Finally, let me ask you to think about this: Is this about something else? Someone new is in your space, and sometimes that's hard to take. Just make sure that you're not getting personal about this. I thought I'd put that out there, because you'll come off like the bad guy if she's really not as incompetent as you say. That may be why your supervisor is not getting involved. Just a thought.

Good luck and let us know how things worked out. Pam
 
I understand that this is a difficult situation for you and likely your practice, too.
It strikes me that your situation seems a combination of performance and also conduct. Her refusal to comply with written policies makes it conduct; her inability to comprehend outcomes of her actions points toward performance impairment.
Pam makes some excellent recommendations. However, I'd also add that when you go to review coding quality, be sure that you tie this back to reimbursement also. In my experience, physician practices often times see compliance to regulation and best practices as antithetical to revenue generation. If you could demonstrate otherwise, that would encourage action on management's part.
Do you think that working more closely with her by means of training would generate improvement? Honestly, though people have been doing a job for years does not necessarily mean they understand the necessity behind certain practices or even what we might consider requisite background in a subject. I suppose I'm hinting that she might need some remedial training. It would seem reasonable for your practice to maybe enact a 100% prospective audit of her work, though that will slow down productivity substantially. It might be still be an idea worth pursuing.
My concern rests with inconsistent application of policy in this situation. That is certainly a compliance risk should anything more come of her coding.
Good luck to you.
 
Pam and Kevin,

Thank you so much for your input. Honestly, I am happy to have another coder on board. That means I am able to have time to take off and not have the work load pile up on my desk. I've worked with a team of coders prior to this job and I am well aware of each coder having their own thinking process, which having policies and procedures set the guidelines on how coding is done for each facility. As fellow coders, I am sure you can relate to being meticulous and following set rules and guidelines, for we know the repercussions of inaccurate billing. So when errors and denials were being presented to me of her work, I followed protocol and went to my supervisor who in turn informed me to speak with her and inform her of our policies. Unfortunately, she is a remote coder so the only means of communication have been limited to email. Which I have sent her several emails. She clearly is capable, I just fear that this resides in the "no one likes to be corrected" category. Which I can easily relate to, so I have approached her in the means of "this is how we do it here, per my supervisor", "We are a great team and need to be consistent with coding to not cause attention to be audited", "We consistently bill these procedures and when not billed we loose money and it's inconsistent", "Let's work together". I give friendly updates and reminders. On going for 4 months with no changes, I almost feel disrespected. Which in turn have me contemplate if a territory factor was at stake, as Pam stated, so I stepped back to reevaluate the situation and myself. I guess as a coder I like documentation to back up my key points. I have turned to Google to research documentation to support me and have found very few articles. But I was hoping for something a little more concrete.

Although, Pam I really like your idea of addressing becoming the Coding Supervisor. Who doesn't like a promotion. I love my job and I love the facility I work for and have a lot of respect for the physicians I work for. I just would hate for 2 coders to continue to butt heads and cause our facility to loose money and get audited.
 
I was taught to bill and sequence CPT in descending dollar amounts. The highest paying CPT is billed on line 1, next highest on line 2 and so on. See this blurb: "C. Carrier Claims Processing System Requirements, #10. Rank the surgeries subject to the multiple surgery rules (indicator '2' in descending order by the Medicare fee schedule amount."

Sequencing of ICD-9 codes is clearly spelled out within the conventions of the system, the general and chapter-specific guidelines and the tabular listing itself. It may also be "rearranged" according to carrier preferences. Thus, as long as this coder has an ICD-9 manual, she should be using it to help her sequence the diagnosis codes she assigns.

This is the concrete information I can supply. Payer contracts are something that you'll have to review for any preferred sequencing; I find this usually does not occur in many coding departments (which is a pity, as it makes our job guess work).

I do hope these help.
 
Correct Coding

A coders world; arent we a unique group :) When I attend conferences or work with a group of coders I love looking around at our differnces, experience, knowledge, training - the list goes on.

I have been on both sides of a like situation - giving and receiving guidance. Two things jump to mind.

First; delivery counts for a lot. Since I was young, I have never responded well to "do it this way because it has always been done this way". Especially with coding. Being guided by coding guidelines and payor contract requirements has motivated me more than "do it because I said". So perhaps some guidance with resources, examples or history in the decision making will be advantageous.

Second; coding is so much more than multiple choice match up. As coders we are more along the lines of slueths and educators - telling a picture with codes from clincal documentation. Sometimes the answer is a question. Could this new team member have resources or knowledge she could share with you - sharing information in a learning fashion could benefit and allow for the consistency you desire for the practice.

Good luck with your challege.
 
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