# Who is responsible for selection of level of service?



## Vanessa123 (Apr 28, 2010)

I am just curious to see how other practices do their billing. We have two coders in our office, but we are not actually in with the physicians offices. We do the billing for a multispeciality group. They send over their fee tickets and we are to review them before we send them out to a billing company. We have some physicians who are on EMR and we have access to that. 

Let's say a fee ticket comes over with no office level circled. Are we to just go on EMR and select the office level ourselves or send it back to the physician to indicate that?

Or we have mulitple CPT codes circled and according to EMR these things weren't done. For instance, Fee ticket has 99396 and 99211 circled. The cheif complaint is follow up evauation of a biopsy. No dication of a pap or anything else of that matter. I would think this would be just a 99211 depending on the what procedure was billed for the biopsy. It could just be a post op visit. This is a constant issue with this doctor. The fee tickets do not match the EMR. One came over with 99203,99386 and no well woman exam was indicated on EMR but it says he did an I&D but just wrote that next to the dx. How would you handle this?

I am just curious to see if anybody else has major issues like this with their physicians.

Thank you.


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## AHVC (Apr 28, 2010)

Based on what you wrote, you have a serious problem with workflow process, provider education, and EMR documentation, not to mention your coding practices. 

If you have 2 coders, what exactly are they doing?  Are they not reviewing all the documentation and coding then providing feedback to the providers on what should or should not be coded and also providing education on documentation requirements?

As you know if it is not documented properly you cannot code for it.  If the provider states he did do these things then the documentation needs to reflect this or it cannot be billed.  As far as the instances where they are providing 2 E/M codes, does the documentation meet the requirements and if so, is the secondary E/M code being modified with a 25?

I would definitely say it is a time for reviewing all of the coding and documentation processes in place in your practice.


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## dwaldman (Apr 28, 2010)

Physician's are smart but if you don't complain about every little coding mistake they make about their code selection on the EMR. They will not learn the steps to set up some codes in the ICD-9 and CPT code summary. If you send it back enough times it will be more of a hassle for them to do it wrong then make some corrections on some charts you send back and start to not make those mistakes in the future.  The doctors have to understand that the superbill matching the EMR helps prevent billing errors that reach the carriers. You can't have a good relationship with the physician if he chronically writing CPTs on the superbill that do not match the EMR. You have contact him or write him note saying I am trying make sure what was done matches what I bill. Also request for the  diagnoses to be numbered on the superbill so you know what first listed diagnosis is.


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## mitchellde (Apr 29, 2010)

I strongly disagree with coding from a superbill.  I do not think a coder should do this ever.  It is the coders responsibility to read the documentation and determine the correct diagnosis codes and the order to list them in given the guidelines and the documentation.  The coder is also responsible for seleting the correct CPT codes and to evaluate the E&M to be certain the level selected is correct.  There is no reason the superbill should match the codes selected by the coder but the codes selected for the claim MUST match the documentation in the chart.  Most physicians do not know the coding guidelines and truely do not have the time to study this and make correct code selections.  That is why we have coders.  If the physician does submit codes and even the order of the dx, the coder may change any of this in order to match the documentation.


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## Pam Brooks (Apr 29, 2010)

To answer your question, the physicians are ultimately responsible for every charge and diagnosis they submit with their signature.  

However, it would be to their advantage to learn and accept the support of certified coders.  With the implementation of EMR, many practices have had to reorganize their workflow; however with providers that have little or no idea of code sequencing, procedural coding and claim edit issues, it would make sense to do complete front-end analysis of all records prior to claim drop.  You can then provide training to assist them with code selection,  eventually moving to a less intensive analysis..  I disagree with holding a coder responsible if any physician _insists_ on billing or coding inappropriately.  However I would strongly encourage coders to always obtain documentation of any coding recommendation or query that the providers disagree with, in case an audit uncovers a problem.  This way the coder can show that they made the appropriate recommendation and the provider chose not to follow it.  I also disagree that physicians 'don't understand' coding.  I supervise a staff who codes for nearly 90 physicians, both primary and specialty care, and I would say that our physicians are extremely coding-savvy...due to the excellent efforts of this staff with education and support.  Our external audits range in the 90% accuracy rate, so it's very possible to get your physicians up to speed with E&M, procedures and ICD-9, with or without an EMR.  

Initially, with new providers, it is ideal to scrutinize every claim prior to submission, it's nevertheless a cumbersome and costly process.  Evenutally, with excellent training, coders can then focus on back-end audits and ongoing education.


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## dwaldman (Apr 29, 2010)

The reason I believe the superbill matching the EMR  is important is that it can let you know the amount of understanding they have about what documentation is required to meet which level. If they are writing on the superbill a high level but they are not meeting the criteria of that level, this is a indication to you need to let them know in order for this be billed at the level you wrote on the superbill this requires the following . If you don't consider the code selection on the superbill valid and just code the visit based on the coding guidelines while you are reviewing the EMR you are not attempting to teach the doctors what is required for what level. Making them responsible for indicating what the first listed dx helps them understand that this is important part of  billing. Maybe this is not a problem for others but when you have a mulitple codes to describe similiar conditions I find hard sometimes to determine what should be listed first.


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## mitchellde (Apr 29, 2010)

Pam Brooks said:


> To answer your question, the physicians are ultimately responsible for every charge and diagnosis they submit with their signature.
> 
> However, it would be to their advantage to learn and accept the support of certified coders.  With the implementation of EMR, many practices have had to reorganize their workflow; however with providers that have little or no idea of code sequencing, procedural coding and claim edit issues, it would make sense to do complete front-end analysis of all records prior to claim drop.  You can then provide training to assist them with code selection,  eventually moving to a less intensive analysis..  I disagree with holding a coder responsible if any physician _insists_ on billing or coding inappropriately.  However I would strongly encourage coders to always obtain documentation of any coding recommendation or query that the providers disagree with, in case an audit uncovers a problem.  This way the coder can show that they made the appropriate recommendation and the provider chose not to follow it.  I also disagree that physicians 'don't understand' coding.  I supervise a staff who codes for nearly 90 physicians, both primary and specialty care, and I would say that our physicians are extremely coding-savvy...due to the excellent efforts of this staff with education and support.  Our external audits range in the 90% accuracy rate, so it's very possible to get your physicians up to speed with E&M, procedures and ICD-9, with or without an EMR.
> 
> Initially, with new providers, it is ideal to scrutinize every claim prior to submission, it's nevertheless a cumbersome and costly process.  Evenutally, with excellent training, coders can then focus on back-end audits and ongoing education.



I agree the physician is responsible they always are.  However the coder is also responsible for the codes they assign to the claim.  If they know the physician is requested inappropriate coding for an encounter then the coder has a responsibility to change the codes to match the documentation.  To code anything not documented is to submit a fraudulent claim.   Having taught coding to physicians and nurses and coders, I do know that most physicians do not understand the coding process, while they may understand the codes they are not privy to the coding guidelines and are not aware that there are certain rules regarding first-listed only or mandatory paired code scenarios, or CCI edits and need for modifiers or non modifiable combinations.  I have only come across a handful that do have more than a basic grasp.  I have never felt that the physician should be responsible for code assignment that to me is the coders job.  With the documentation to guide them a coder can change the physicians codes, and can change the order of the code and can change the visit level as long as the documentation supports those choices.


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## Pam Brooks (Apr 29, 2010)

mitchellde said:


> I have never felt that the physician should be responsible for code assignment that to me is the coders job.  With the documentation to guide them a coder can change the physicians codes, and can change the order of the code and can change the visit level as long as the documentation supports those choices.



I guess we'll have to agree to disagree! None of my providers are ever comfortable with a coder making a change in LOS without their approval and here's why:  Our providers are bonused based on the level of RVUs they generate on a monthly basis.  This is a common reimbursement model. Although 99% of the time our providers agree with the coding recommendations we provide, we will not make any level of service change without their approval, because it affects their bottom line.  Our facility maintains that the provider is liable for all of their submitted claims, and frankly, the payer expects the same.  After all, the it is the providers that are credentialled by the payers, not the coders!   And probably less than 5% of encounters are returned to our providers for coding recommendations, because we've made it our job to make sure that they have excellent training in E&M.   We do have an arrangement that allows us to re-order any assigned diagnosis codes as long as the documentation supports the diagnosis order, but LOS changes are virtually never made without provider approval.   

I'm not saying that this is the only way to code, I'm  just saying it's our way.  Ultimately the coding and billing arrangements have to meet the needs of everyone involved.


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## mitchellde (Apr 29, 2010)

While we may disagree, and your manager thinks the physician is the only one responsible, the AAPC a few years back did publish several articles regarding coder liability.  The bottom line was that the coder that assignes the code to the claim is also equally responsible for the code assignment.  If the coder suspects or knows that the codes requested by the physician are not supported by the docuemntation then that coder is liable for any penalties assessed along with the physician.   The coder should, I agree discuss with the physician any changes they feel need to be made to the coding but in the end the coder should assign no codes that are not supported by the documentation.  Coders when well trained are extremely knowledgeable and professional and are very capable of correct code assignment.  I applaud your faciltiy for your ongoing physician education but you must accept that this is not true in all offices or facilities.  SO in the end you and I disagree and others out there can see both sides of this issue and make infgormed decisions on how they wish to run their office.  Thank you for the animated discussion I love these!


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## Vanessa123 (Apr 30, 2010)

Thank you all for your input and guidance. This has been my first job since I became a coder. I have not had the experience of working for a physician in their office, to be able to be there while things are being performed, and on site to ask the physican questions. I find it a bit difficult in the situation that I am in to be able to have a smooth communication with the physicians. I know that is my job as a coder to educate the physicians. 

It's kinda hard to really say what it is are company does. We are the middle people. We have roughly around 24 physicians with more to come that we get their fee tickets sent over daily. We are not located in the building with any of the physicians. Only about 11 are on EMR. What we are to do is review the fee tickets for those who aren't on EMR to make sure that everything is filled out correctly and that the codes circled aren't conflicting with the dx's. We do not have access to the patient's medical record. If we have a concern about the fee ticket we send a note to the doctor. And we do not enter in any charges or do any billing. After we have reviewed the fee tickets and coded all surgeries we then send them off to a billing service, where they do all the charge entry and insurance follow up. 

As for the physicians that are using the EMR, we look over the EMR and see if what the EMR says matches what the fee ticket says. We have a major issue with some of the physicians on EMR. I am not sure if they were not properly educated on how to use EMR or what the issue is but it makes it very hard to review their office visits. 

We have fee tickets come over all the time missing CPT codes. We are told by our manager that if nothing is circled and they are on EMR we are to go on EMR and decipher which level of service to bill. 

They way that I feel, this should not be up to me. I think that the physician should be indicating what level of service they should bill for and my job to review and if I see that he/she has not coded correctly, then it would be my job to let them know there is a issue. 

I don't know if any of you work in a similiar place that we do. 

Thanks again.


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## Lisa Bledsoe (May 3, 2010)

I think a lot of this has to do with the job description of the coders.  I for one am the only coder for a 65+ physician office.  I spend most of my time cleaning up the messes on the back end.  I would LOVE to have more coders (the providers code for themselves) and take that out of the providers hands; but the clinic partnership has opted not to pay coders to do this.  I have mentioned many times that they could cut back in the A/R dept if they would hire more coders, but since we all know coders earn more than an A/R rep, they prefer it the other way.  It is not cost effective or preferable in my mind, but the bottom line is I don't own the practice.  As far as my job description - it's clean up and education...


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