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Is it appropriate to not code a service because you know it will be denied

  1. #1
    Default Is it appropriate to not code a service because you know it will be denied
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    Is it appropriate to not code a service because you know it will be denied? Recently I attended a rev cycle group meeting that discussed denials and common issues. One of them was 36415 being denied consistently. The suggestion was to leave this item off the claim all together for those payers denying the entire claim due to this cpt. I do not bill, so my opinion is this, I find it acceptable to leave it off the claim if the payer does not cover it and the claim is being denied. However, that being said I still believe coders need to pick that charge up and code the cpt in the encoder. As a coder, I was trained to code what services were provided regardless if the procedure/cpt is a covered service. I think of it for a compliance purpose, we need to track and monitor what services are coded and provided. Its what was done during the time of service so we code it. Now if the billing department needs to leave that off the claim due to denial, that's a separate issue to me. Please provide your thoughts.

  2. #2
    Cool Removing CPT 36415 off the claim
    I use to bill this CPT 36415 with the correct ICD10 diagnosis code and lab test per the physician's order. It did get paid but it depends on your payer regs in billing this CPT 36415 service. There will be times when a physician or his nurse will try to bill CPT codes such as CPT 94760 or 96360 which are bundled into surgery codes. So you should not bill these 2 CPT codes. In this case I would remove these codes because it will not get paid and they come under the bundling rule. If a provider selected the wrong CPT code, and you know the correct CPT code per the documentation correct it before transmitted.

    Also you need to understand the abstrating coding particulars around certain CPT codes billed, such as place of service, diagnosis given, medical specialty and the specific coding convention & CPT parenthetical instructions; such as trigger point injections vs vaccinations, laceration repair, Etc. Check out your rules and guides in the CPT, HCPCS and ICD10 manuals plus Goggle information or YouTube if you must.

    I hope that helps you

    Lady T

  3. #3
    Default Same question and no good answers
    I have a very similar situation (with different codes) going on and I feel the same way about it. I am a coder for an outpatient facility.
    I feel like when I code, the CPTs that I send out should accurately reflect the entire procedure (or procedures) performed, making sure there are no edits on my end...and whatever billing does down the line is their concern, not mine.

    We are currently being told not to code 76872 an transrectal ultrasound, as they get an edit in billing. Apparently, as it is charged, the CPT 76872 is sent across from the billing department and then that CPT appears twice on the bill and causes them an edit. I feel like they need to do whatever they need to do to get rid of the extra charge and clear their edit. They are saying to prevent the doubling error just don't code CPT 76872. It gets added in by them anyway down the road.
    How do I KNOW they are adding it after the fact? Sometimes that is the ONLY CPT code we have to send on accounts.

    I feel like that claim needs to leave my hands correctly and they need to do what they need to do to insure it leaves their area correctly as well. It's exhausting because they just think they can say leave it off and it should be done. I want to stick to the coding guidelines, regardless of what a non-coding educated billing employee thinks is just a simple change.

  4. #4
    Default To bill or not to bill
    Medical Billing
    Over the years I have had many similar debates with billers. I look at myself as wearing two hats the coder and the biller and I don't wear them at the same time if i can help it.

    It has always been my practice to code all services (within coding guidelines) regardless of what I call "payability".There are many reasons for this.

    1. It reinforces that all patient encounters will be billed completely and with indifference to anything other than the coding/payer rules.
    2. In the event that an error is discovered based on contracts or other sources that show the service should have been paid then you would be able to produce the claims information showing
    how much you are owed. I realize this doesn't happen a lot but it has happened.
    3. If a provider is on an RVU contract, they should get credit for services rendered (I realize the codes referenced above don't have RVU's)

    These are just my thoughts. good luck and keep up the good fight!
    Hollee Hamilton

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