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  1. Default Documentation-labs
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    If the doctor is ordering labs for a certain dx but that dx will not pay, but the patient DOES happen to have a covered dx for the labs, can we use that covered dx instead?

    For example...just today I see thyroid studies ordered and done for anemia. Well, 285.9 will cover with Medicare, but 280.9 won't. The patient has 280.9-the one that is not covered BUT the patient DOES have fatigue...780.79 which will cover. So, is it ok to use fatigue instead of anemia even though he says "ordered for anemia" ?

    Amanda, CPC
    Urology coder

  2. #2
    I wouldn't advise coding based on what will pay if it's not supported by the'd be setting yourself up for trouble. The diagnosis code that you assign to each CPT code is what payers use to determine medical necessity (without reviewing the records, anyways), so if it's not an obvious connection (like thyroid testing for anemia), the doctor is just going to delay their reimbursement, if they get any at all. I'd suggest pulling up clinical policies from the insurers you're dealing with on a case by case basis, to show the doctor what indications the insurers consider medically necessary or experimental/unproven for the procedures in question. They usually have extremely detailed rationale to explain their stance.

    I suspect that the doctor is probably just not communicating their thoughts well in this case. Just guessing, here, but it sounds like maybe they suspect anemia as the cause of the fatigue, but are running a thyroid test to rule out thyroid problems as the source. If that is the case, they should work on phrasing in their documentation, so they're not misunderstood to sound like they're ordering unnecessary labs. CMS documentation guidelines say "If not documented, the rationale for ordering diagnostic and other ancillary services should be easily inferred." The physician should make an addendum to the record to make the reason for the thyroid test a little more clear, since they went out of their way to mention the anemia, in the first place. If they had just listed the lab by itself, then I'd be more comfortable with assigning a code based on signs and symptoms. It's hard to say for sure without actually seeing the chart, though...Hope that's helpful!

    Brandi Tadlock, CPC, CPMA

  3. Default
    Yes, that helps very much!! I need to just relay to them that they don't have to state a reason and it actually hinders us coders when they do. So, as an auditor, if the documentation says for anemia, but we use fatigue, what would/could you do to us as a clinic? Go as far as recoup money? Or does it just vary from auditor to auditor?

    Amanda, CPC
    Urology coder

  4. #4
    I'm not an auditor for a payer or an authority, so I couldn't tell you how that might play out with one of them, but I'd suspect that the worst case scenario would be legal trouble from the OIG for fraudulent billing. BUT only if fatigue isn't mentioned at all in the medical record. Payers might recoup payment in this situation if they did a post payment audit and discovered that the doctor indicated that the lab was for anemia, and you billed it with the fatigue diagnosis, only because of how the note was worded.

    If I were auditing it, I would tell them how it would look if it was coded based on the literal interpretation of the note, and point out that it would cause a denied claim. Then, I might suggest that he simply list the labs ordered in one area, and list the suspected diagnoses and any signs and symptoms that he felt were relevant to his decision making separately, to allow for the auditor/coder to draw the correct inference of which conditions were prompting the diagnostic services. If he is ordering a lab or test that doesn't seem to fit in with the signs/symptoms/or suspected diagnoses, he should then mention what he's looking for with the test, so that the medical necessity is easier to convey.

    A good way to look at good documentation is - instead of the doctor making notes solely to satisfy requirements or as a memory aid, make notes as though they're writing them to teach someone else how to practice medicine just like they do. They should give details on what they observed, how they interpreted those observations, and what they decided to do about it, and it should be easy enough to follow for people that haven't gone through 8 years of medical school. That doesn't mean he has to necessarily write more than he has been, but just make connecting the dots a little easier for someone who's not thinking on the same level as an experienced physician. It will come across as flattering, rather than insulting, so they might be more open to your suggestions.

  5. Default
    We definitly would not bill a dx out that was not in the medical record, that's why it was sort of a gray's like well, he says he's doing the test for THIS dx, BUT this OTHER dx that the pt has will pay, so the coders I have worked with have justified it by saying, it's not like we're coding something that the pt doesn't have, which is true, BUT doesn't seem right when the doc specifically states what he's doing the test for.

    That was a great suggestion about how to educate them on how to document. I too think that would be more of a flattering way. And we all know how some docs can have some major 'God' complexes!! I don't know if it's an Oncologist thing, but some of mine in the practice sure do! It's hard to tell them anything. That's why I hope I'm ok in an event of an audit as long as I document PER Dr. X, this is what is going on....etc.

    I've only been certified for a year and a half and have only been coding that long, so it's THESE kind of questions that get me! It's hard to learn real world stuff in a coding class....the ICD-9 guideline world is much different than real world sometimes. I would say that's the hardest part about medical billing.

    But, ANYWAY, thank you so much for your insight!! It's great that we can get on here and network with each other. Otherwise, as a new coder I would be lost at times!

    Amanda, CPC
    Urology coder

  6. #6
    I've been doing this for 3 years - and I learn new things all of the time. My favorite part about this field is that you can learn, and learn, and learn some more, and you'll still be challenged on a regular basis. It's hard to get burnt out on something when you're always encountering new situations! I'm glad I was able to help! Have a great day!

  7. Default
    Medical Billing
    OH yes, LOTS to learn all the time!!

    Amanda, CPC
    Urology coder

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