# superbills vs medical records



## cpccoder2008 (Jun 8, 2010)

I would like to get general feed back for coders billing for physician's and hospitals of mutli specialties with 50+ doctor's. Do you use superbills and let the physician's be responsible for coding or do you code from the medical records ? I understand how a small private practise would work since you have full access to the medical records and usually have the chart handed to you upon the patient checking out but what about big practises that simply cannot code and check out every patient or a hospital billing for physicians or ASC ? How do you handlge the coding process ? 

Thanks for any feedback and again this is just a friendly little discussion.


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## CoderCat (Jun 8, 2010)

I work for a billing group associated with a hospital that handles several specialties.  We bill using the superbill and let the physician decide the level of E/M.  The diagnosis is written in and has to be coded.


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## mitchellde (Jun 8, 2010)

I feel very strongly that it must always be derived from the medical record.  The coding guidelines state " the entire record should be reviewed to determine the reason for the encounter".  Physicians are not coders and often they miss so many things that we can catch.   Also I worked in a large outpatient facility where we had over 60 physicians and we had 3 coders and read every word for every clinic encounter and ever surgery.  I have also worked in large physician practices and again I always read every chart note.


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## eadun2000 (Jun 14, 2010)

I agree 100% with Debra.  I personally would NEVER code from a superbill.  If I do not have the encounter, I sure as heck would not code it.


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## muthershyp (Jun 14, 2010)

Super bills are mandated by administration in our 300 physician practice.  As coders we have had no say in the process.  Physicians receive training and once they pass an audit, coders just data enter for them.  They are audited every 6 months.  If they fail an audit, their encounters will be abstracted by the coders until they once again pass.


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## CoderCat (Jun 15, 2010)

With us the option is not there.  We are given the superbill to code it period.  The physicians here are also trained on chosing the codes.  Some of the specialist associated with the same hospital do no even have coders they code everything themselves.  We don't bill for those groups though.  I guess it just depends on the level of training the physicians have with regards to compliance.


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## Anna Weaver (Jun 15, 2010)

We also code from superbills and when we have a question on it, we go to the record. I do not, and have never agreed with this. But, as posted above, we didn't have a choice here. So, when the physician signs the superbill, and that's what we code from, who is held responsible? Are we as coders/data entry responsible? Is the physician? I would say about 80-85% of the time, the superbill does not match the documentation. Where do we go from here? The positions we have as coders for our physicians are new positions. They are less than 2 years old and we are trying to determine the correct way to do things. Any thoughts? Would appreciate any and all feed-back.


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## GaPeach77 (Jun 23, 2010)

How can the coder explain their reasoning for assigning codes without viewing supporting documentation? The coder is responsible for explaining their level of coding if audited.  I work in a Peds hospital which have speciality practices as well. We code for over 75 physicians and surgeons. I can't imagine coding from med charts either with that many physicians. We received the superbills and enter the MRN number into a program that pulls up the dictation. All physicians are required to dictate their visits and surgeries regardless.  If its not dictated then its not done.


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## GaPeach77 (Jun 23, 2010)

Anna Weaver said:


> We also code from superbills and when we have a question on it, we go to the record. I do not, and have never agreed with this. But, as posted above, we didn't have a choice here. So, when the physician signs the superbill, and that's what we code from, who is held responsible? Are we as coders/data entry responsible? Is the physician? I would say about 80-85% of the time, the superbill does not match the documentation. Where do we go from here? The positions we have as coders for our physicians are new positions. They are less than 2 years old and we are trying to determine the correct way to do things. Any thoughts? Would appreciate any and all feed-back.[/QUOTE
> 
> I have been down this road. I know exactly what you are dealing with. I spent years traveling to physician offices auditing and restructuring.  And even now everytime we get a new speciality added on we have to go through the same scenario. Let me explain how to approach this, in a way that the physician can come to terms of how important coding really is. For starters, you have to bill from some kind of medical record or dictation. Physicians prefer dication because its quick and they will speak more of what they have done then write, especially if they are surgeons.  General practice is ok for charts. Specialist should be dictating because of higher paying levels and insurance companies want specific documentation on file. If you can get a few important physicians on that dictation wagon or the Chief or whoever then thats the best way to go for coding.  If you are not there yet, then the best way to reach them is to show them. Make this a project if you can, its time consuming, but will pay off in the end.  Gather as many med records as you can and recode the ones that have a higher code then the one the physician has marked on the superbill. Show them the difference in $$$$ and create a spreadsheet with a final calculation. Wait until it builds up to a substantial number before presenting it.  After many years of going back and forth with this, I realized that a spreadsheet calculating the difference in what a coder has coded and a physician has coded speaks way louder and quicker then a coder's words. Something about seeing the amount in dollars makes a difference. A physician has to see the value of the knowledge of a coder.  Another thing that the coders and the physicians need is a relationship that lets the physician know that  you are not just pulling codes out of a book, that you are really trying to get him reimbursed as much as possible and ethically for the services he has provided. To get to that level with the physician, ask some of the physicians to explain certain procedures they may do to a few of the coders, especially the top dollar surgeries or procedures. Arrange it to be in a conference room if can or something professional. You can even get CEU's approve by AAPC for it as well. Contact them and they will tell you how.  Make an appointment with the physician and ask them do they mind explaining briefly this or that certain procedure or certain diagnosis so that you can be sure to include all the correct codes or additional codes.  Physicians are busy, but out of 60 physicians you will find more then half that would love to elaborate on  what they do. This gives the physician confidence that the coders have a clue and it also gives the coders a chance to ask questions letting the physician know their interest and knowledge level. I have seen many physicians eyes literally light up with surprise when a coder ask or elaborates on a procedure. And remember not to take it personal, many physicians really have no clue of the knowledge level of a coder until we let them know what we know. Trust me, start this process and before you know it the physicians will be coming to the coders and asking them coding/procedure/reimbursement type questions.  One last thing, make it clear to the physician that a coder is credentialed and certified,therefore, ultimately responsible for coding of a legal document and can be held accountable for it. We may not be licensed, but our credential is our bread and butter and it can be lost if coding guidelines are not followed correctly. Coders do have responsibility for how things are coded and are held accountable because a claim can turn into a legal document overnite when dealing with worker's comp, third party liability, malpractice, disability, etc. A physician can always refer to his medical records, but a coder has to explain why the claim has the codes that it has and that should be made clear to any physician.
> Good Luck!
> ...


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## Anna Weaver (Jun 24, 2010)

Thank you Simone, all wonderful suggestions and we will discuss this (my co-worker and myself). Thanks again, I truly appreciate you taking your time to answer this.


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