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What gives the doc the right to choose E/M?

  1. #1
    Location
    Salt Lake North
    Posts
    620
    Cool What gives the doc the right to choose E/M?
    Medical Coding Books
    I work for a clinic where the docs choose their own level of E/M. Being a CPC and knowing how to count bullets, I can tell you that docs can't choose the correct E/M level. I had a talk with my hospital administrator today who told me that if I change a code (usually down but up too) that I need to get written permission from the doc for this! I told him that since I was a certified coder that I was ultimately responsible for the code selection and that it was my butt on the line in times of audit.

    When we get audited, can I say "Don't fine me, it was the doc that chose the code" ???

    Please let me know of your experiences.

    Thanks

  2. #2
    Location
    Columbia, MO
    Posts
    12,531
    Default
    Whne I coded for the physicians, if I was not allowed to change the selected E&M to the documented E&M, then I would not code the claim at all and it would sit until the physician either amended the documentation to match the level or allowed me to code it correctly. A lot of claims did not get reimbursed due to timely filing befor they realized I was serious. This might not work in your case But that was how I handled it.

    Debra A. Mitchell, MSPH, CPC-H

  3. #3
    Default
    Why are you reviewing the documentation and billing?

    If you are doing a prebill audit and they won't let you change anything, that is a huge problem in my opinion. It sounds like lip service to me, and I have been in that position before. They want to say "we are compliant everything was checked by a certified coder before it went out" then when it hits the fan they blame you and let you take the fall. Not cool. Document everything.

    If you are doing retro audits for compliance and they won't let you change anything, then you need to practice major CYA. Document everything, get everything in writing. There is probably a policy that states the physician has to approve any changes, get a hold of that and keep it. Keep copies of everything you are auditing, your findings, recommendations, who you told and the outcome.

    Hopefully your issues are due to a lack of understanding on the part of your employer and you will be able to change that based on the information you compile and present to them.

    As I stated, I have been there, and I had to walk away. I refused to bill claims for 3 providers because they were commiting out and out fraud. I had in writing from one of them admitting she falsified her charts and I have personally witness (along with a manager and another coworker) one of the others go back and change his records so he could bill a certain code. The claims backed up about 5 months, then I was pulled in an office with 3 high level managers and told I had to push all those claims thru that day as they were. My name would have been on every single one of those and every single one was an act of fraud. I turned in my resignation less than an hour after that meeting. I do want to clarify that my issue wasn't just about E/M leveling, it wasn't my interpretation of guidelines, it was billing non-covered services in a way to get them paid by government and other payers. So everything from E/M up to MRIs were involved.

    Hopefully mine is a worst case scenario you won't ever have to experience.

    Good luck,

    Laura, CPC

    Stand for what is right, even if you have to stand alone.

  4. #4
    Location
    Columbia, MO
    Posts
    12,531
    Default
    The documentation should always be reviewed before submitting the codes assigned to a superbill. I would never assume any codes were correct without my examination of the documentation. We are not just "code pushers" we are professional coders and our job is to review the documentation and assign the correct codes. We do need to stand up for what is right in our profession. But I agree with Laura, you may have to be willing to walk to another job.

    Debra A. Mitchell, MSPH, CPC-H

  5. #5
    Location
    Salt Lake North
    Posts
    620
    Cool Thanks for your input
    Thanks for your input, it really helps. I'm good at E/M coding and can verify a level of service fairly well. I'm still learning of course. I have one doc that marks a level 4 E/M code for anything. I pull the chart and of course change it to the correct level. Thanks again.

  6. #6
    Location
    Milwaukee WI
    Posts
    4,466
    Default What are you job duties?
    Quinnweb writes: I work for a clinic where the docs choose their own level of E/M. Being a CPC and knowing how to count bullets, I can tell you that docs can't choose the correct E/M level. I had a talk with my hospital administrator today who told me that if I change a code (usually down but up too) that I need to get written permission from the doc for this! I told him that since I was a certified coder that I was ultimately responsible for the code selection and that it was my butt on the line in times of audit.

    While the other posters have very valid points with respect to requirements of a coder ... no where in your post do you say that "coder" is your job title or job responsibility. Your position may not include this function. There are many CPCs working today in positions that are not specifically "coding." And there are CPCs who are working as "coders" who don't actually code.

    In our very large practice our surgical coders code directly from the operative report. And our inpatient coders also abstract the charges from the documentation in the hospital charts. But the coders who process our clinic charges do NOT do any pre-bill audit/verification. It is the responsibility of the provider to accurately code his/her clinic charges. Do they make mistakes. You bet your bippy they do. But we have regular retro audits with refunds to payers as appropriate (or new claims for missed charges in some cases). These retro audits also serve as an education tool for the practice (and if a specific physician has too many "dings" s/he gets individual education on appropriate E/M coding and more frequent audits until improvement is steady). Of course, all these protocols/guidelines are written and understood by everyone ... including the coders. (And yes, they are all CPCs.)

    So, before you get overly upset about being at risk personally for incorrect coding, be sure you understand the protocols of your employer. By all means get the guidelines / protocols for your practice in writing and keep them in your employee manual. If there is no employee manual, offer to create one.

    Basically, what I'm trying to say is that your boss may be correct to say that it is the provider who is responsible for using the correct code. But you still have an ethical responsibility as a professional coder to use your expertise to achieve correct and compliant coding. And your employer is lucky to have someone dedicated to this profession on their staff.

    Best of luck to you.

    F Tessa Bartels, CPC, CEMC

  7. #7
    Default
    Quote Originally Posted by katmryn78 View Post
    Why are you reviewing the documentation and billing?

    If you are doing a prebill audit and they won't let you change anything, that is a huge problem in my opinion. It sounds like lip service to me, and I have been in that position before. They want to say "we are compliant everything was checked by a certified coder before it went out" then when it hits the fan they blame you and let you take the fall. Not cool. Document everything.

    If you are doing retro audits for compliance and they won't let you change anything, then you need to practice major CYA. Document everything, get everything in writing. There is probably a policy that states the physician has to approve any changes, get a hold of that and keep it. Keep copies of everything you are auditing, your findings, recommendations, who you told and the outcome.

    Hopefully your issues are due to a lack of understanding on the part of your employer and you will be able to change that based on the information you compile and present to them.

    As I stated, I have been there, and I had to walk away. I refused to bill claims for 3 providers because they were commiting out and out fraud. I had in writing from one of them admitting she falsified her charts and I have personally witness (along with a manager and another coworker) one of the others go back and change his records so he could bill a certain code. The claims backed up about 5 months, then I was pulled in an office with 3 high level managers and told I had to push all those claims thru that day as they were. My name would have been on every single one of those and every single one was an act of fraud. I turned in my resignation less than an hour after that meeting. I do want to clarify that my issue wasn't just about E/M leveling, it wasn't my interpretation of guidelines, it was billing non-covered services in a way to get them paid by government and other payers. So everything from E/M up to MRIs were involved.

    Hopefully mine is a worst case scenario you won't ever have to experience.

    Good luck,

    Laura, CPC

    Stand for what is right, even if you have to stand alone.

    Laura, I sooo admire your courage and conviction and I can only hope that I would do the same in that situation. Kudos to you!!

  8. #8
    Location
    Salt Lake North
    Posts
    620
    Cool
    Thanks for all of your input. I have two docs that don't see many patients. One I think is upcoding out of ignorence, the other, is upcoding intentionally. One chooses a level 4 for almost any visit. I know that a level 4 visit with the DX(s) would trigger a red flag at the insurance company. I know that if I don't buy it, the insurance company won't either and will want to see documentation eventually. Many office visits that are marked as level 4 are barely a level two when I audit them. And I do change them. I also have a couple of docs that are on top of it, document very well, and I can routinely bump up their claims to level 4 from level 3 very easily. One of the docs complained about another doc upcoding so much knowing that it would trigger an audit! He did'nt know that I was correcting the codes before they were billed. Even though I have been asked as a coder to "Review" the codes, I am the only certified coder in the office and I know it would be my hide on the line if we had a bad audit.

  9. #9
    Location
    Greeley, Colorado
    Posts
    2,045
    Exclamation
    Quote Originally Posted by FTessaBartels View Post
    Quinnweb writes: I work for a clinic where the docs choose their own level of E/M. Being a CPC and knowing how to count bullets, I can tell you that docs can't choose the correct E/M level. I had a talk with my hospital administrator today who told me that if I change a code (usually down but up too) that I need to get written permission from the doc for this! I told him that since I was a certified coder that I was ultimately responsible for the code selection and that it was my butt on the line in times of audit.

    While the other posters have very valid points with respect to requirements of a coder ... no where in your post do you say that "coder" is your job title or job responsibility. Your position may not include this function. There are many CPCs working today in positions that are not specifically "coding." And there are CPCs who are working as "coders" who don't actually code.

    In our very large practice our surgical coders code directly from the operative report. And our inpatient coders also abstract the charges from the documentation in the hospital charts. But the coders who process our clinic charges do NOT do any pre-bill audit/verification. It is the responsibility of the provider to accurately code his/her clinic charges. Do they make mistakes. You bet your bippy they do. But we have regular retro audits with refunds to payers as appropriate (or new claims for missed charges in some cases). These retro audits also serve as an education tool for the practice (and if a specific physician has too many "dings" s/he gets individual education on appropriate E/M coding and more frequent audits until improvement is steady). Of course, all these protocols/guidelines are written and understood by everyone ... including the coders. (And yes, they are all CPCs.)

    So, before you get overly upset about being at risk personally for incorrect coding, be sure you understand the protocols of your employer. By all means get the guidelines / protocols for your practice in writing and keep them in your employee manual. If there is no employee manual, offer to create one.

    Basically, what I'm trying to say is that your boss may be correct to say that it is the provider who is responsible for using the correct code. But you still have an ethical responsibility as a professional coder to use your expertise to achieve correct and compliant coding. And your employer is lucky to have someone dedicated to this profession on their staff.

    Best of luck to you.

    F Tessa Bartels, CPC, CEMC
    I fully agree with what Tessa has said here. For my employer, it is ultimately the provider's responsibility to choose the correct code(s). Once a discrepency occurs either with patients or insurance, that's where I step in and determine whether or not the correct level of service was reported. I also perform retro and pre-audits as well as education for the providers on many coding topics; E/M being the number one topic. I believe it is the job description and responsibilities that determines the ultimate responsibility you carry as far as coding. You cannot be responsible for every code reported...that would be a very daunting task, and unrealistic as well.
    Lisa Bledsoe, CPC, CPMA

  10. #10
    Location
    Greenville, SC
    Posts
    51
    Default
    I completely agree with all of your posts, but like one of you stated, it is ultimately the physician that has his/her name on the claim as the billing provider. That is why, in my hospital, we are responsible for discussing this with the physician, but ultimately, the physician must "sign off" on the changes for billing purposes.

    Good luck to you.

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