We also code from superbills and when we have a question on it, we go to the record. I do not, and have never agreed with this. But, as posted above, we didn't have a choice here. So, when the physician signs the superbill, and that's what we code from, who is held responsible? Are we as coders/data entry responsible? Is the physician? I would say about 80-85% of the time, the superbill does not match the documentation. Where do we go from here? The positions we have as coders for our physicians are new positions. They are less than 2 years old and we are trying to determine the correct way to do things. Any thoughts? Would appreciate any and all feed-back.[/QUOTE
I have been down this road. I know exactly what you are dealing with. I spent years traveling to physician offices auditing and restructuring. And even now everytime we get a new speciality added on we have to go through the same scenario. Let me explain how to approach this, in a way that the physician can come to terms of how important coding really is. For starters, you have to bill from some kind of medical record or dictation. Physicians prefer dication because its quick and they will speak more of what they have done then write, especially if they are surgeons. General practice is ok for charts. Specialist should be dictating because of higher paying levels and insurance companies want specific documentation on file. If you can get a few important physicians on that dictation wagon or the Chief or whoever then thats the best way to go for coding. If you are not there yet, then the best way to reach them is to show them. Make this a project if you can, its time consuming, but will pay off in the end. Gather as many med records as you can and recode the ones that have a higher code then the one the physician has marked on the superbill. Show them the difference in $$$$ and create a spreadsheet with a final calculation. Wait until it builds up to a substantial number before presenting it. After many years of going back and forth with this, I realized that a spreadsheet calculating the difference in what a coder has coded and a physician has coded speaks way louder and quicker then a coder's words. Something about seeing the amount in dollars makes a difference. A physician has to see the value of the knowledge of a coder. Another thing that the coders and the physicians need is a relationship that lets the physician know that you are not just pulling codes out of a book, that you are really trying to get him reimbursed as much as possible and ethically for the services he has provided. To get to that level with the physician, ask some of the physicians to explain certain procedures they may do to a few of the coders, especially the top dollar surgeries or procedures. Arrange it to be in a conference room if can or something professional. You can even get CEU's approve by AAPC for it as well. Contact them and they will tell you how. Make an appointment with the physician and ask them do they mind explaining briefly this or that certain procedure or certain diagnosis so that you can be sure to include all the correct codes or additional codes. Physicians are busy, but out of 60 physicians you will find more then half that would love to elaborate on what they do. This gives the physician confidence that the coders have a clue and it also gives the coders a chance to ask questions letting the physician know their interest and knowledge level. I have seen many physicians eyes literally light up with surprise when a coder ask or elaborates on a procedure. And remember not to take it personal, many physicians really have no clue of the knowledge level of a coder until we let them know what we know. Trust me, start this process and before you know it the physicians will be coming to the coders and asking them coding/procedure/reimbursement type questions. One last thing, make it clear to the physician that a coder is credentialed and certified,therefore, ultimately responsible for coding of a legal document and can be held accountable for it. We may not be licensed, but our credential is our bread and butter and it can be lost if coding guidelines are not followed correctly. Coders do have responsibility for how things are coded and are held accountable because a claim can turn into a legal document overnite when dealing with worker's comp, third party liability, malpractice, disability, etc. A physician can always refer to his medical records, but a coder has to explain why the claim has the codes that it has and that should be made clear to any physician.
Good Luck!
Simone, CPC