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Thread: Billing and Coding Compliance

  1. #1

    Exclamation Billing and Coding Compliance

    AAPC: Back to School
    Good Day Fellow Coders,

    I am doing some research regarding Billing and Compliance and have a general question for the Subject Matter experts in the field of Billing and Coding Compliance.

    A claim is denied by an Insurance carrier as the CPT code does not match the age of the patient for a specific date of service based upn the patients age at the time of service. The physician is the person responsible for the Integrity of the CPT and ICD-9 Diagnosis code selected for this specific date of service via the Encounter form.

    A Third-Party Biller within the Patient Accounts Department who is not a CPC changes the CPT code for the date of service based upon the patients age within the EMR for the specific date of service. The Third Party biller does not verify the correct CPT code selection via the EMR and or documentation from the Physician(Encounter Form) for the specific date of service. The Third Party Biller does not reach out to the Physician of record for the date of service to verify that the incorrect CPT code was chosen. The Third Party Biller just changes the CPT code without reaching out to the Physician of record, A coder within the organization, or the Supervisor, Manager or Director of Patient Accounts within the Organization.

    If the Organization was Audited the Encounter form (Physicians Order) for the specific date of service will not match the Organizations EMR. Would like be considered Biling Fraud as what was documented does not match the service for what was billed??

  2. #2


    The documentation that must match the billed service, is the office note not the encounter form. If the documentation is not clear then you should query the physician. If it was clearly the incorrect CPT code then why wouldn't you change it?

    Why would the phyician be responsible for the correct codes? That is why there are professional coders. We allow the physician to treat the patient and we do the coding.

  3. #3

    Lightbulb Billing and Compliance


    Thanks for the prompt responce.

    If the Third-Party Biller is not a CPC and can not intepret what the Physician did on the specific date of service via the EMR in the documentation the Third-Party Biller should not change the CPT code without clarification from the Physician of record, a CPC, Supervisor, Manager or Director.

    So if the documenation and encounter form for the date of service state for example 99212and the Third Party-Biller changes it to 99213 without proper training and outreach to the appopriate staff if an Audit took place the documentation via the EMR does not match the service billed for the specific date of service this would be considered FRAUD???

  4. #4
    Join Date
    Apr 2007
    Columbia, MO


    Yes that is correct. Also it is physician reponsibility as well as the biller responsibility. Codes should not be assigned not changed without a review of the medical record. An encounter form with only codes assigned by the provider is insufficient for assignment of the codes to the claim. A coder must always review the documentation and a biller or coder can not change the codes without a review of the documentation. Anytime codes are submitted that can not be supported by the documentation there exisit the probablity of being called fraud.

    Debra A. Mitchell, MSPH, CPC-H

  5. #5

    Talking Billing and Compliance

    Thanks for the prompt and honest responce.

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