Was I wrong?

cfitzgibbons

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I work for the home care/pharmacy department of a medical facility. I was asked for coding for a patient who was having bilateral surgical procedures and was going to be receiving lovenox as a prophylaxis. This patient also has the dx of spastic diplegic CP. There is no history of any thrombosis of any kind in this patients history. I also did not see any documentation of any concerning blood work that would point to a concern for a possible blood clot. After going around with multiple nurses regarding this and stating there is no documentation supporting this, I finally responded that I was not going to jeopardize my certification that i worked hard to earn for this. They even went to the point of providing codes that they thought were relevant. I responded that none of the codes provided were supported in any documentation and this was my final response in this discussion. To me, this would be fraud and I do not want to be a part in this. Was I wrong to be upset by this?
 

thomas7331

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What codes were they asking you for and why? I'm not sure I completely understand what your situation was or what was the purpose of the codes that were being requested of you. But keep in mind, fraud only occurs when someone intentionally submits incorrect information on a claim for payment. There is no fraud involved in discussing coding with caregivers or payers in advance of a procedure. In my experience, it's pretty common for nursing staff to need to be able to provide some codes in advance of procedures for purposes of prior authorizations or estimations of payments, or for other utilization management needs. Payers understand that codes given in advance are preliminary, not yet final and could change depending on the what actually occurs, and are also subject to review after the fact. Payments and benefits are not determined until a claim and request for payment is actually received, and the false claims act, to my knowledge, doesn't apply to the prior authorization process. All that said, if you did your best and could not come up with codes and gave them that as your final answer, then there's no reason to be upset - it just needs to go up the chain of command at that point - that's what managers and supervisor are paid for, so that when staff can't resolve an issue, they can take the appropriate action.
 
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cfitzgibbons

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Thomas,

The dx code that I provided was Z29.8 - Encounter for other specified prophylactic measures. What was occurring is that the patient's insurance would not authorize this medication with this diagnosis. The other dx that were suggested by the patient nurse practioner, but not documented anywhere in the patient records were Z74.01 -Bed confinement status, R29.5 - Transient paralysis, Z74.09 - Other reduced mobility, Z73.6 - Limitation of activities due to disability, R26.9 - Unspecified abnormalities of gait and mobility. None of other are supported by any of the documentation that I reviewed. Plus, I would doubt that any of these would justify authorization for the lovenox. I think that if people in the health care setting don't already know that this is wrong, I was right in letting them know in no uncertain terms that this was unacceptable. Your thoughts, Thomas?
 

thomas7331

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I agree with your code choice on this as the best, and agree that you can't code something that isn't documented. I think perhaps a diagnosis based on the patient surgical status or condition requiring the procedure may be other options to try too.

My thoughts, though, since you asked :), are that this is a little bit of an unusual situation again because they're trying to get an authorization for a patient's future needs, and not submitting a claim based on something that has already happened - and really, the doctor could document any of those situations in order to meet the payer's requirements - for example, the doctor could certify that the patient would be confined to bed and thereby make that a legitimate code use. This is more of a bureaucratic hurdle and a red tape issue than a typical claims/correct coding situation. If the payer is going to cover the surgery, then in all likelihood that are also going to cover the drugs that are required for that surgery and it's just a matter of figuring out what information exactly their system needs for that to happen. Insurance company computers are not programmed by coders and don't always make good coding sense, and the bottom line here is not a coding question, but a question of whether this patient's plan covers this or not. Really the proper way to handle this would be for someone to get on the phone and explain this to a human being at the insurance company and ask them what code or what kind of information they're looking for in this situation, and then if at the end of the day they really and simply just don't provide coverage for this drug to a patient having knee surgery, well, then the patient is just going to have to take that up with their plan of pay for it themselves. Again, really something that should be escalated off to a supervisor to handle instead of having your staff running in circles looking for imaginary codes, though I know that's often easier said than done.

Hope all that helps some!
 
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mitchellde

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To go farther, I always think the codes need to relate the story in order to be able to communicate medical necessity. I would use the condition the patient has that needs the surgery followed by the Z29.8. It is often standard that prior to surgery patients with certain conditions require prophylactic medications to "get them in condition" for the surgery. Also any relevant other conditions the patient may currently have that are documented.
 
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