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19103 one incision 2 biopsies

  1. Default 19103 one incision 2 biopsies
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    the surgeon performed a vacuum assisted breast biopsy on the left breast. he made one incision and did two biopsies within that incision. i told him that he could only bill this as one unit. he insisted that the front desk staff post it as two seperate procedures. i feel that he is commiting fraud by knowing enforcing the front desk to post these charges. i provided him documentation that clearly stated the number of incisions not the number of biopsies determine the billing. the centers for medicare and medicaid even state that it does not allow the reporting of a separete procedure when it is performed at the same patient encounter as another procedure in an anatomically related area through the same skin incision, orifice, or surgical approach.

    i spoke with my office manager and told her of my concerns. this is not his first time of doing this. i have gotten denials and then after reviewing the documentation knew that i could not appeal that he was incorrectly reporting the surgery. he does not feel the rule applies to him. that his cases are "unique". i am in a compromised position as i feel everyone in the office is. he is putting everyone at risk of an audit and possible repricutions of the audit. how should this be handled??

  2. #2
    Columbia, MO
    Is he using the same code twice with a 59? If so then I do disagree with this. If you are the coder then do you supply the codes for the claim? If so then why does the front desk change your codes? They are not coders. I would post the way I know is correct. The AAPC Coding Edge had an article a few years back that stated that at some point you must ask yourself how much your coding ethics are worth to you. If you have an employer insist you do something you know is incorrect and you risk losing your job to do it correct then then your choices are to do the right thing and face the the dismissal or do as you are requested and face possible fines and/or penalties.
    There is one other solution and that is the use of the 22 modifier if you feel documentation can support it.

    Debra A. Mitchell, MSPH, CPC-H

  3. Default
    no he is giving it to them on a super bill to post. the front desk questioned me about how to post it. i asked wether or not he had made one incision. the nurse phoned and said that yes only one incision had been made. i post the facility charges. the front desk posts the office charges.

  4. #4
    Columbia, MO
    Hmmmmmmmmmm I would not post any code without the documentation in front of me to support the code. I have done both facility and physician coding and never without the documentation. There is no way to really know unless you see it.

    Debra A. Mitchell, MSPH, CPC-H

  5. Default
    yes mam i agree and wish it were so at our practice. the doctors coe their own procedures for the office and the facility. the front desk staff at the 3 offices we have do not question the doctors. occasionally they will question me as they did the other day for clarification. the facility charges that i post, unless it is a something that is pretty self explanatory such as an appy or gallbladder i will pull the op report, review it, and attach it to the billing. we have one physician though and that is the one that did the breast biopsy that does not want to conform to cpt coding rules. he is getting more and more demanding that things be posted that were not even documented. i went round and round with him a couple of weeks ago about him wanting to use cpt 38740. no where in his op report did he describe if the axillary lymphadnectomy superficial or complete. the only thing i got out of the op report was a 19303,19125, and 38792. he demanded that i bill it though with the 38740 he stated incorrectly as we all know that it should be implied wether or not he documented it. i have worked for these physicians for over 10 years and it has been wonderful. 3 years ago they allowed me to start telecommuting. now though i keep feeling like the dr is asking me to repeatedly do things that i know are incorrect and he will not listen. i told the office manager i would not send out the claim from the other day until they addressed the issue with him.

  6. #6
    Columbia, MO
    Wow , Tammy If I were in your shoes I would probably start looking for another position. You just cannot post codes that are not reflected in the documentation. Each time you do that it is intentional fraud. Each time you post codes without looking at the documentation it is potential fraud. I hate to be so harsh but that is reality. So many payers are checking claims carefully and auditing, as they know the documentation is getting more and more slim. Sometimes you just have to stand up for what is correct. Physican by and large are not coders so I always ask why do you have them do it? Their time is better spent attending to patients and documentation, our time must be spent reading the documentation to determine the correct codes. I left a good paying position recently for that very reason, and I have no regrets, no job is worth my professional ethics being compromised. I hope you are able to resolve things and remeber we are always here for you.

    Debra A. Mitchell, MSPH, CPC-H

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