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Coders acting as 'billing scrubbers'

  1. #1
    Default Coders acting as 'billing scrubbers'
    Medical Coding Books
    Perhaps this is common practice but I'd like to know if this is the case elsewhere.

    We as coders are being directed to 'scrub' every case and every single code before it goes to billing so that the claims are completely clean. We have to go out on the internet and search websites to be certain each and EVERY code we use will completely pass BEFORE it goes to billing. This way the billers will just do data entry and send the claims out without having to determine if there are codes that will not pass.

    Of course we recognize codes that are inappropriate and tests that obviously are lacking documentation support and we do query the physicians.

    Is this common practice to search a list of websites before coding each single code to avoid billing issues? What is the billers responsibility in this particular process? It seems excessive and inappropriate.

    Any insight as to how other hospitals handle this method of research? We want to do the right thing but are wondering if this is how it is done elsewhere.

    Thanks!

  2. #2
    Location
    Columbia, MO
    Posts
    12,531
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    I am not sure what your process is. Coders should always read the documentation and code only what is documented regardless of the codes submitted by the provider. A coder should have access to the CCI edits to be able to identify component of comprehensive and mutually exclusive parings and should then appropriately apply the modifiers that are needed or drop codes if necessary. In otherwords, a coder should submit to the biller a clean claim. Yes that I do feel is correct. To check with the payers regarding coverage issues? no that is not a coder responsibility. I am not sure what you mean by searching a list of websites, I would purchase either encoder pro or code correct or some eqyuivalent web based system that allows a coder to quickly and easily obtain the CCI edits as well as other relavent coding information.

    Debra A. Mitchell, MSPH, CPC-H

  3. #3
    Default
    Hi Debra,

    I finally am able to get into code correct. My question is this: do coders have to go to Code Correct every single time they code a case? Some cases are obviously appropriate, some are not. So if the physician fails to document a dx that will not cover a test or proceedure it is the coders to know this and take steps to rectify it?

  4. #4
    Location
    Columbia, MO
    Posts
    12,531
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    If the physician documents a condition that is not medically indicated for a test then no in no way is this a coder issue to deal with.. We code from documentation, In this case you pass it on and then if it is denied for medical necessity you can appeal. If you know the documentation is too vague and needs clarification then yes you query the physician befor you code it. When the physician orders a test or procedure it should be the nurse or techs job to verify the medical necessity befor it is performed... in my opinion and a perfect world. I disagree with questioning the physician regarding the diagnosis he has rendered when we feel the test or procedure will not be covered. I am not sure if I have helped in any way.. this is just my opinion!

    Debra A. Mitchell, MSPH, CPC-H

  5. #5
    Default
    I disagree with questioning the physician regarding the diagnosis he has rendered when we feel the test or procedure will not be covered. I am not sure if I have helped in any way.. this is just my opinion![/QUOTE]

    Yes Debra that is what we are asked to do, match the test with the diagnosis and if it won't pass for payment then we have to go to the doctor for further information. So in this manner we must understand, interpret and challenge everything. Further we are going to be handed a stack of claims that did not 'pass' for payment and see what was wrong with them. To me this is a billing function and I guess I want to know if this is a typical coding job.

  6. #6
    Location
    Louisville, KY
    Posts
    1,101
    Default
    Perhaps the issue is that billing is not working with coding to resolve these. Depending on where you work, the identification of "unclean" claims may be either coder or biller work. I'm with you in thinking that the billing department has a stake in the process. It is the coder, though, who has the expertise to research and possibly correct these matters.

    As for working with and challenging providers, that is simply education. We no longer have a health care system that is set up (payment-wise) so that if the doctor orders the procedure it is automatically paid. Truthfully, this makes your value very evident to the providers, who may have no experience or understanding of payer medical necessity. They do not generally receive training on the "business" of medicine while in medical school and certainly not during any residency at a teaching hospital. Even if they did receive that from their time in residency, it wouldn't apply to physician coding and reimbursement, but only to hospital-based services.

    Regardless, see if your coders and billers can share this task in some way. I see absolutely nothing wrong with coders performing this level of work--it is very much within our scope. Additionally, the coders conducting this task will likely need the assistance of claims scrubber (which I believe you've discussed in the thread) and utilize that to help create clean claims.

  7. #7
    Default Thank you
    Regardless, see if your coders and billers can share this task in some way. I see absolutely nothing wrong with coders performing this level of work--it is very much within our scope. Additionally, the coders conducting this task will likely need the assistance of claims scrubber (which I believe you've discussed in the thread) and utilize that to help create clean claims.[/QUOTE]

    Kevin thank you so very much for clarifying and supporting this information. We are undergoing great change and many new and evidently needed ideas are surfacing. Your explanation will make it easier for us to move forward. L

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