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Thread: Coding Blind

  1. #1

    Question Coding Blind

    AAPC: Back to School
    As a Coder, I often abstract E/M levels, Procedures and Diagnoses from reports.
    If I never see, or have knowledge of the Payer's responses to the claims I have coded, how do I know if I am coding these encounters correctly and within the AAPC Code of Ethics?
    In short, what external response is required to recognize an AAPC certified individual as a competent coder?
    Just being certified does not seem functional in the work place to me.
    How does the AAPC feel about certified coders that are hired to "Code Blind" without ever seeing, knowing, and/or having access to Payer Responses to the claims they have coded?

  2. #2

    Smile Payers

    I also know from billing experience that most payers include coding advice and/or advisories with their RA.

  3. #3
    Join Date
    Apr 2007
    Albany, New York


    Just an additional comment....

    I code Amb Surg for a hospital and have on occasion (regarding some difficult cases) called the surgeons office to query what code(s) the office used.
    Sometimes the responses have been helpful, and other times the repsonses have been so off, based on the OP report I had in front of me. This is because some of these offices do not have the OP report that the surgeon dictated available to them, and just go by what code(s) they are "told" to use.
    So, in response to what Kevin said......it's not only the payors that can provide incorrect/ unsupported information.
    And, at times even people doing the auditing can get it wrong.
    I've learned that I have to trust in myself and if I can back up what I've done, then I'm okay with it.
    Karen Maloney, CPC
    Data Quality Specialist

  4. #4
    Join Date
    Apr 2007
    Louisville, KY


    The first assumption to your argument is that the payers render appropriate guidance. Such is not the case--just ask an experienced retrospective auditor or denial manager. Payers get it wrong also.

    In my mind, a coder's job should be primarily "blind" as you refer to it. Keeping billing and coding functions separate (or in the least, distinct) heads off any tendency to "code to be paid." I constantly see folks on the forum confuse the two duties. One does not equal to the other.

    The second assumption is that being paid equates with being correctly coded; this just is not so. The longer I've stayed in the field and the more variety in my job duties, the more I've seen that what's coded, what's billed and what's paid are three independent spheres in the revenue cycle. To code for something you basically need two things: 1.) documentation to support code assignment and 2.) a designated code (or set) to capture the service. Minus coding edit logic, you're good to go.

    In order to bill for something, coverage, policy, contract and payer-dependent rules apply. Just because a service is "code-able" does not make it "billable". Lastly, what's paid is completely determined by the payer and theoretically contractual obligation toward the provider.

    In each of these elements the determination of quality is judged against a seprate standard. Essentially coding captures charges and codes, billing submits appropriate code/charge sets for reimbursement and payers adjudicate claims based on their independent criteria.

    While I understand that sometimes coders are required to use that independent criteria of the payers, it isn't necessarily that the coder's work is validated by that group. Internal or external audits of your coding should be the objective determination of your quality--not the arbitrary and unique rules of the payer group. However, even that statement isn't absolute.

    I'm not sure this has helped, but let it serve as an argument in support of a more objective determination of coder qualification than payer response...
    Kevin B. Shields, RHIT, CPCO, CCS, CPC, COC, CCS-P, CPC-P, CPC-I

  5. #5
    Join Date
    Apr 2007
    Duluth, Minnesota


    that was VERY WELL stated! I agree 100% with your comments! rather than reiterate everything you've already stated so clearly, I'll simply say again,... very well said, I agree 100%

    Last edited by dmaec; 01-12-2009 at 08:14 PM. Reason: it's reiterate :) not reiderate... ;)
    Donna, CPC, CPC-H

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