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Help I Need some Advice

  1. Default Infertility medical management
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    I agree with Rebecca.

    Brandi, what are the guidelines in your district for timebased coding? I do not see any mention of that in your post. I could have missed it.

    Even if you are only going to cling to Medicare guidelines, I would think that infertility is exactly the type of DX that was in mind when they came up with the time-based coding guidelines.

    There are times when the "medical necessity" as defined cannot be identified however the treatment/counseling is no less complex and detailed.

    We make it a practice to first check for a medical necessity code and when the scope of the work cannot be documented and billed under that, we owe it to the providers and the patients to fairly code it based on time if the factors are there.

    This may garner some feedback, but in my opinion, especially in reading posts on this site, some coders seem to take pride in "keeping it low".

    Unreasonable and ill-defined reasoning for that goal is one of the chief reasons there is often such friction between coders and providers.

    Even though there is a way to achieve a better reimburseemnt for the provider it is ignored in favor of defending a lower code. That is not, in my opinion, the way a coder should function.

    Let's be a part of the solution

  2. #12
    Default
    Quote Originally Posted by MMAYCOCK View Post
    I agree with Rebecca.

    Brandi, what are the guidelines in your district for timebased coding? I do not see any mention of that in your post. I could have missed it.

    Even if you are only going to cling to Medicare guidelines, I would think that infertility is exactly the type of DX that was in mind when they came up with the time-based coding guidelines.

    There are times when the "medical necessity" as defined cannot be identified however the treatment/counseling is no less complex and detailed.

    We make it a practice to first check for a medical necessity code and when the scope of the work cannot be documented and billed under that, we owe it to the providers and the patients to fairly code it based on time if the factors are there.

    This may garner some feedback, but in my opinion, especially in reading posts on this site, some coders seem to take pride in "keeping it low".

    Unreasonable and ill-defined reasoning for that goal is one of the chief reasons there is often such friction between coders and providers.

    Even though there is a way to achieve a better reimburseemnt for the provider it is ignored in favor of defending a lower code. That is not, in my opinion, the way a coder should function.

    Let's be a part of the solution
    I get the feeling that I'm offending some of you - sorry! I'm really not trying to. I don't disagree with Rebecca, and I'm not looking for an argument, but I'm not going to back down on my opinion of this issue. Somehow we've gotten off of the topic of the original post, which was a single visit about infertility that morphed into a well-check at the last minute; I didn't mention anything about coding based on time, because it's not a factor in this particular situation - the point of the post was that the provider documented NO counseling. However, if that kind of information were documented, I'd be all for assigning a code that would appropriately describe the services rendered.

    "Keeping it low" should not be a goal for coders - 'keeping it accurate', should. If the doctor did the work and documented it correctly, then they should be compensated fairly; but we should not try to make any encounter out to be greater than it actually was, for the sake of reimbursement. Although Medicare won't be adjudicating this claim (probably not any claim relating to infertility, really - I can't think of too many 65 year olds trying to get pregnant, but I'm sure they're out there...), the fact remains that commercial payers recognize and utilize CMS documentation guidelines in their payment policies, and their requirements are certainly not more forgiving. Coding a visit at a higher level just because CMS is never going to see it isn't a practice I'd recommend. Abusive billing practices are abusive billing practices, no matter which arena they're in.

    To be perfectly clear, I'm talking about this encounter, not all encounters. I have no problem with doctors getting paid. But, if this patient came in for infertility, and the provider didn't document any counseling, or the amount of time spent in a discussion, or anything that suggested that their medical decision making had even the slightest degree of complexity, such as plans to find the cause of, or manage the infertility - then it would not be appropriate to assign a high level problem-oriented E/M, or a preventive E/M...even if most encounters for infertility usually warrant a higher level of service. Documentation requirements aren't arbitrary rules created to make doctors' jobs harder - they are designed to make sure that the minimum amount of information needed to understand the patient's problem, and the doctor's impressions and treatment plan for that problem, are recorded at every visit, in case someone else ever needs to know, and they're not around to ask. The only way to enforce those (perfectly reasonable) rules, is to link them to reimbursement. If the doctor feels that they should be paid more, then they should reflect that in their documentation, and not rely on coders to 'get creative' with their code assignments. It's part of their job, whether they like it or not; it's not our place to help them find a way to circumvent the system and get paid full price for only doing half of the work they're supposed to do. We're coders, not corporate tax attorneys.

  3. Default
    "It's part of their job, whether they like it or not; it's not our place to help them find a way to circumvent the system and get paid full price for only doing half of the work they're supposed to do. We're coders, not corporate tax attorneys. "

    That's the attitude I'm referring to. If we are the ones who study it, why wouldn't it be our job to help them? Why would you consider it circumventing the system to help the provider learn how to make the necessary documentation changes? Why is that even the assumption made from my post? Are the only choices you see "keep it low" or "circumvent the system"?
    Imagine if we went to a doctor with the same perspective on care.
    This superior attitude is really at the root of the problem between providers and coders. I'm not offended and I'm not looking for a fight either. Just that the root of the issue in the responses here is so often reflected in other posts that I wanted to address it.

  4. #14
    Default
    Quote Originally Posted by MMAYCOCK View Post
    That's the attitude I'm referring to. If we are the ones who study it, why wouldn't it be our job to help them? Why would you consider it circumventing the system to help the provider learn how to make the necessary documentation changes? Why is that even the assumption made from my post? Are the only choices you see "keep it low" or "circumvent the system"?
    Imagine if we went to a doctor with the same perspective on care.
    This superior attitude is really at the root of the problem between providers and coders. I'm not offended and I'm not looking for a fight either. Just that the root of the issue in the responses here is so often reflected in other posts that I wanted to address it.
    The only choice I see it 'do it right'. Not keep it low, not circumvent the system - code based on what is there, not what should be there. It is our job to educate providers on documentation requirements, not to help them by ignoring the requirements.

    But you're right; it's not fair for me to assume that you were advocating upcoding in your post. There has to be a balance between maximizing reimbursement and maintaining compliance, and no one-size-fits-all attitude will ever be able to achieve that goal. One should not be sacrificed in the interest of the other, and sometimes that means that there will be disagreements between providers and coders, as to whether or not the documentation makes the grade to reach the reimbursement that's desired. If having that belief makes me an elitist who's part of the problem, then I guess I know where I stand. But I'm not going to apologize for thinking that rules weren't made to be broken, and I'm sure that I'll continue to convey that 'superior' message in future posts. You're welcome to disagree - it's a free country, and you're entitled to your opinion, too.

  5. Default
    I never doubted you would continue in your vein. You make it sound very noble. Happy coding to everyone!

  6. #16
    Default
    Duly noted.

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