I presently work in an acute hospital setting as an ED coder. Our billing dept. is constantly reviewing our dx codes (especially for Medicare/medicaid) accounts and they are always asking us to look for additional codes to add so that we can get payment. In fact, one biller in particular, actually gets into our accts. and adds codes so that payment can be made. I was always taught in school that billing and coding should be at opposite ends of the spectrum, and that neither should have any clue as to what each other is doing nor have access to each others work. Doesn't this constitute fraud? This situation has more than a few a us coders nervous! 

I also work as a coder for ED and in my facility it is not possible to change codes by billers. We only can code what was documented by a physician in patients' medical record (ED chart).

Ewa

My guess is the the billers are getting edits in the system and/or denials from the insurance companies. 

 I actually think it's a good idea to look at claims before they go out and compare them to the CCI, LCDs, NCDs, etc.  As long as the billers aren't just picking any old code to get the claim paid, then it's  not fraud.. but this may be something you can address with your compliance department.  There should definitely be something in writing about this process. 

At my last job, I had all the coders review everything (e.g. for Medicare pts review for any LCDs).  If we knew the claim would deny for the dx, we would query the physician and/or request medical records to see if there was 'something better'. 

Here's an example... some of the skin excision codes had LCDs; often times, the docs would just write 'lesion' on the charge ticket, which was not a covered diagnoses.  We would then see if it was actually a neoplasm or some other specific dx.  If so, we'd change to appropriate dx, and if not, we'd submit the claim w/ a -GZ mod.  This saved time in the long run for the people working denials. 

I hope that makes sense!

:) Erica

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Erica D. Schwalm, CPC-GSS, CMRS www.ericacodes.com

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Erica D. Schwalm, CPC, CPC-GENSG, CMRS

www.ericacodes.com

http://health.groups.yahoo.com/group/ericacodes/

~ Free Physician Billing & Coding Resources

http://www.ericacodes.com/camio.html
Citizens Against Medical Information Offshoring

Tell your Compliance Officer what the billing department is doing.  I'll guarantee you it will stop.

 Coding is a direct reflection of a physician's order or documentation.   The physician is the only person who can "amend" the original order or documentation.  Even then, a coder should always consider the circumstance for the change.  For reimbursement only, constitutes FRAUD.  But if the clinic notes or ED records documentation clearly supports the change, then and only then are you ethically able to make the change and have the account rebilled.  Be sure to place account notes to protect yourself.

Couple thoughts here:

 When a patient presents for service, the order diagnosis along with the ordered test should be ran through a Medical Necessity program.  If the ordered diagnosis fails, an ABN is your only option at this point.  Once the patient has left, it's too late.  CMS clearly states that only a signed ABN gives the facility the opportunity to bill the patient, as they chose to have the service even though Medicare may not cover.  Otherwise you'll more then likely end up writing it off.

CMS and the OIG have clear regulations on physician "queries".  They are to be written as a clarification when his documentation isn't clear.  If you suggest or have him pick from some examples, this is considered leading and could possibly raise a red flag for a audit, which potentially carries fines and penalities to your facility, besides being smeared all over the media....

Your example should work if you can refer to a path report and query for diagnosis clarification.

Hi Ewa it is me kelly..

.i just wanted to say that when I got my first coding job at a small hospital there was a biller who ALWAYS came down to our office and wanted something added or changed. The coders shared an office with the HIM manager.....when she would come to me I would say I am not changing a code. They didn't have a way to change or add codes. I told her if I didnt see it documetned I wasn't going to add anything therefore I would not be commiting fraud.  Made for an interesting work day sometimes.

I am the Health Information Department Manager at a small hospital and do most of the inpatient coding.  I do have to agree that billing should not change the codes on an account without consulting the Coding Department but I also think the Coding and Billing Departments must have a good working relationship.  There are so many rules and regulations influencing both of these departments which, in turn, effect our payments. If there is not a good working relationship between the departments, it can very adversely affect the revenue cycle.  We cannot be at odds with our Billing Department or our Admissions/Financial Counseling Department.  We should all work together to learn from each other the best way to get the information needed to get clean bills out and get our accounts paid in a timely manner. 

 

Our Admissions Manager, Financial Counseling Manager, Business Office Manager, CEO, and I have weekly meetings to discuss any issues we are having getting information we need from other departments in the hospital, our outsource billing company, insurance companies, Physician offices, AR Days, Coding days, etc...We all work together to try to get any issues worked through and move on to the next challenge.  This keeps the lines of communication open and we are also held accountable to the CEO for what is going on in our respective departments.

Great response Kayla and I agree.  I'm a former Mgr of a large healthcare instituation and know too of the value a good relationship between the Health Information Management Department and the Central Billing Office/Patient Accounting Department can be to the Revenue Cycle. 

 It is true, they see edits within SSI that often times prevent the claim from final billing appropriately due to edits.  It is possible these edits may be corrected by revisions to diagnosis or procedure codes.  The relationship at JHSMH between the two departments leads to the CBO/PA contacting HIM Coding to review the documentation within the record for possible revisions...at no time do the Billers make these revisions.  With this, review and revisions are made in a timely manner and does not affect AR days in an adverse way.