# E&M codes on superbills by physician



## lsmft (Aug 30, 2009)

Superbills come over from the physician offices for coding/billing at our office. The E&M codes are check marked by the physician but there is no doucumentation.  The actual diagnoses are handwritten. How do I know if the physician has selected the correct code? How can I know if there is additional information that will make the claim more accurate?

This makes me very uncomfortable. Shouldn't there be documentation to support these things? 

I am new to office coding.

Thanks!


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## mitchellde (Aug 30, 2009)

I know others will disagree with me but I would never code a claim without the documentation.  I have observed too many times where the superbill has no representation to the documentation at all so I do not rely on them.   I tell the physicians I work with that if there is no documentation there will be no claim.


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## blonde01 (Aug 30, 2009)

I would love to agree with you on that.  Unfortunately, not every clinic is running this way yet.  In the clinic that I am at currently does not have the previledge of getting the chart with the superbill to enter charges.  Most companies hire employees that do not have any billing or coding background and the "corporate view" is that they are trusting the physicians are checking off the correct office level and writing or checking off the correct ICD-9 to it's highest specifity.  This causes a major problem.  If the clinics do not have someone that recognizes or that can catch potential mistakes in billing other than the physician, there are higher rates in denials.  I am saying this from experience.  I also feel uncomfortable creating claims with just a superbill and no documentation to double check to make sure that there is nothing missed.  

Together, we Professional Coders need to convience "Coporate Thinking" of the importance of having Professional Coders employed with in clinics as well as off site.  The Professional Coders in the clinics can catch errors before they are made and the off site Professional Coders and focus more on Audits and Education, etc....


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## lsmft (Aug 31, 2009)

Thank you both, I had an idea this might be a grey area of sorts. It helps to know what the current practice is out there.  Thanks so much, L


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## kbarron (Aug 31, 2009)

I do the same thing. We get the encounter with the E&M circled and dx circled also. Sometimes the dx is written in. We have to have all MCR charges pulled and given to another person. We are on a time limit for Medicare charges. We are a CAH.


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## nc_coder (Aug 31, 2009)

I have worked for 3 different physician offices. 
 Every one of them have operated this way.  The physician marks the level of service and the diagnosis.  I have voiced my opinion of being uncomfortable with this.  But I also understand the fact that we can't always wait for the dictation to be transcribed.  That's where internal audits and physician education becomes very important.


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## FTessaBartels (Aug 31, 2009)

*Clinic charges vs inpatient vs surgery*

First - I'm at a major academic medical center. Our "practice" has over 1,000 providers.  So to say we're a big outfit is an understatement.

Hospital based charges (ER, consults, admits, surgeries) are all abstracted by professional coders directly from the patient chart documentation.

But, our physicians, NPs, and PAs are responsible for "coding" their own clinic charges. They mark the superbill with the E/M and diagnosis.  The "coder" in our billing office who is responsible for preparing these documents for data entry is not really coding at all ... she is billing. 

All physicians and coders are required to attend annual training sessions provided by our Compliance office.  We perform regular post-billing audits, with reports to the each division chief. If a given provider gets too many "dings," s/he is scheduled for additional individual training. 

Occasionally I'll do a special study of a particular CPT or Dx code and report my findings to our manager. Sometimes there's no issue that needs correction. Recently I found a significant UNDERcoding problem; I'm meeting with the surgeons at 06.30 tomorrow morning!

It's important that each practice have well defined policies and procedures regarding these responsiblities.  I wouldn't stress out over the clinic charges until I fully understood my specific job responsibilities as well as the policies and procedures in place for the practice. Just because reviewing documentation isn't a part of your job responsibility doesn't mean that it isn't being done. 

All that being said, we have a responsibility as a professional coder to do everything we can to ensure that our employers are compliant. 

F Tessa Bartels, CPC, CEMC


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## lsmft (Sep 1, 2009)

F Tessa I appreciate hearing how a major practice handles its coding and billing issues, especially having come from large university settings.

Your response was well thougth out and well written and it gives me insight as to how the rest of the world is working.

Incidentally I have to wonder if the surgeons under code because they are fearful of audit.

Thank you, L


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## blonde01 (Sep 1, 2009)

lsmft said:


> F Tessa I appreciate hearing how a major practice handles its coding and billing issues, especially having come from large university settings.
> 
> Your response was well thougth out and well written and it gives me insight as to how the rest of the world is working.
> 
> ...



I believe that you are right.  I think that alot of physicians out there, especially in my practice, under code because they fear of an audit!


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## ARCPC9491 (Sep 1, 2009)

Just wanted to add that undercoding can spark an audit as well. So commonly we hear about overcoding and fraudulent charges. It's important that together as a team every service provided is coded correctly. Undercoding is usually (though not always) deliberate which can be seen as an inducement, discreminatory, and even fraud and abuse. Other non-deliberate reasons is out of fear, lack of education, etc. Undercoding can very well get you in just as much trouble as overcoding. You are distorting and misrepresenting the service provided. More importantly, correct coding ensures you are properly being reimbursed and you are maximizing your revenue to the fullest potential.


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## blonde01 (Sep 1, 2009)

ARCPC9491 said:


> Just wanted to add that undercoding can spark an audit as well. So commonly we hear about overcoding and fraudulent charges. It's important that together as a team every service provided is coded correctly. Undercoding is usually (though not always) deliberate which can be seen as an inducement, discreminatory, and even fraud and abuse. Other non-deliberate reasons is out of fear, lack of education, etc. Undercoding can very well get you in just as much trouble as overcoding. You are distorting and misrepresenting the service provided. More importantly, correct coding ensures you are properly being reimbursed and you are maximizing your revenue to the fullest potential.



I agree.  Our network has 200 physicians and only 5 coders.  I have just accepted a position as the 5th coder for our network.  My transfer is next week.  Our coders are swamped with these very issues.  I am going into my position with a "Make it Happen" attitude and hopefully I will be able help make the change that we so desperately need.  Our problem is getting the physicians to comply.  We do Annual Education for them, and because I am on THIS side (clinical), I am able to see what really happens after those education seminars.  NOTHING.  The physicians are not open for change.  I will work on changing that to start with!


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