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Legalities of a coder

  1. Exclamation Legalities of a coder
    Medical Coding Books
    The head physician in our office is very emphatic about charging a service that I -as a Certified coder- know is not a billable charge. I have been told by my office manager that I have nothing to worry about, I cannot be held responsible for billing a charge the physician insists I bill. This goes against other things that I have read about my responsiblity by being certified. If we were to be audited, and we are penalized for billing this service, would I be held responsible as a certified coder and possibly penalized as well?

  2. #2
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    Tacoma, WA
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    Quote Originally Posted by nc_coder View Post
    The head physician in our office is very emphatic about charging a service that I -as a Certified coder- know is not a billable charge. I have been told by my office manager that I have nothing to worry about, I cannot be held responsible for billing a charge the physician insists I bill. This goes against other things that I have read about my responsiblity by being certified. If we were to be audited, and we are penalized for billing this service, would I be held responsible as a certified coder and possibly penalized as well?
    Working for a physician, you are covered against liability. In an audit the physician is the ultimate responsible party for the codes that were used.

    If you continue to work for that physician, I would place in the record somewhere your objection to the coding practices and the basis for your objection. If the charge is not billable, is it getting paid? Or is it just denied anyway? If there is potential fraud taking place, you can also anonymously report coding inaccuracies directly to the payer and let them educate the physician.
    Arlene J. Smith, CPC, CPMA, CEMC, COBGC

  3. #3
    Location
    Columbia, MO
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    Quote Originally Posted by nc_coder View Post
    The head physician in our office is very emphatic about charging a service that I -as a Certified coder- know is not a billable charge. I have been told by my office manager that I have nothing to worry about, I cannot be held responsible for billing a charge the physician insists I bill. This goes against other things that I have read about my responsiblity by being certified. If we were to be audited, and we are penalized for billing this service, would I be held responsible as a certified coder and possibly penalized as well?
    Several years back the Coding edge ran a series of articles on coder liability written by an attorney. And the answer is if you know it is wrong and you follow thru anyway then yes you are legally liable for fines and penalties. You are not covered. You would only be covered if you did not know for instance that the documentation was false. The articles went on to state that if you know some thing is incorrect and you do nothing about it as in stop it or report it to the appropriate party ie insurance company, OIG, Medicare, etc. Then you are again equally liable. The AAPC then published an article on your ethics and how much they are worth. They went on to say that again yes you would be liable and the appropriate path is to refuse to engage in the activity and either report the activity if it goes on anyway or leave the job and then report it. You cannot just continue to allow something to go on that you know is wrong nor feel forced into doing something that is knowingly wrong.

    Debra A. Mitchell, MSPH, CPC-H

  4. #4
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    Tacoma, WA
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    Quote Originally Posted by nc_coder View Post
    The head physician in our office is very emphatic about charging a service that I -as a Certified coder- know is not a billable charge. I have been told by my office manager that I have nothing to worry about, I cannot be held responsible for billing a charge the physician insists I bill. This goes against other things that I have read about my responsiblity by being certified. If we were to be audited, and we are penalized for billing this service, would I be held responsible as a certified coder and possibly penalized as well?
    After reading the other posts I went on a search and found the article in the August 2011 Coding Edge written by David Vaugh and attorney who is also CPC certified, he does clearly state that a coder can be held criminally liable for defrauding the government and you don't have to even be the one who put the code in the system. Very interesting article that is quite eye-opening.

    Do not under any circumstances mis-code a claim even at the direction of a physician, you could end up in jail for a very long time.

    "The “take home message” is that if you participate in, agree to, or
    hide improper coding, knowing that it is improper coding, you have
    potential criminal exposure, even if you received no compensation,
    did not actually perform the improper coding, and feared for the loss
    of employment." David Vaughn, JD, CPC, Coding Edge August 2011
    Arlene J. Smith, CPC, CPMA, CEMC, COBGC

  5. Default Thank you
    Thank you both for your replies. You answered exactly the way I was expecting. I even told my manager that I remembered there being an article that I read recently. Thank you for reminding me of the issue it was in. Hopefully, I can take this to her and convince her that something needs to be done. I have worked at this office for 1 1/2 years and have felt uncomfortable about this billing, but didn't want to "rock the boat". My manager actually asked me to look into it and see if other offices were doing it. When the answer was a resounding NO, she said that we would have a very hard time convincing him not to do it. From what I understand, he has been doing this for over 10 years and has been told it is wrong before. I am the first certified coder this office has had. So up until now, the biller that was there was covered under his liability. I am not.

  6. Default
    Maybe it would be possible to have an independent coder not associated with the office do a review. Sometimes the physician will listen to an independent third party.

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