# Did I Miss Something?



## Priscilla Keogh (Apr 20, 2009)

Last week I posted a thread asking for help because my compliance officer had told me I do not have to wait for physician attestation  (I work at a teaching hospital) to bill a procedure.  As long as I informed the physician the E/M charge neede his attestation, it was okay to bill it before he added it.  After a meeting friday to help explain this to me I was also told not to hold a charge because there was no documentation.  Inform the physician  there is no documentation and then go ahead and bill it.  I asked my compliance officer what ever happend to "if it's not documented it didn't happen"  She said that it has been discussed in courts and challenged that just because it was not documented does not mean it didn't happen.  She assured me our corporate lawyers said we will be okay.  Help!! Did I miss some big announcement in the coding world that changed everything,  I need my job but this is crazy:


----------



## veggiecow (Apr 20, 2009)

This probably won't be much help, but I used to work for a billing company that did the same thing. If there was insufficient or no documentation, we would still bill it and send a note to the drs office asking for clarification, etc. We also had a lawyer in our company so I'm sure that they somehow knew this was okay (?) I'm like you though, I still prefer to go by the "if it's not documented, it didn't happen" guideline. It just makes me feel safer. And the company I work with now does go by this guideline. So my hypothesis is maybe it just depends on the company and their policies and procedures?


----------



## dmaec (Apr 20, 2009)

your compliance officer is correct.

If it isn't documented/written, it wasn't done"  IS - good advice, but NOT THE LAW! 

little bit more info.....
Medicare payment is determined by the content of the service, not the content of the medical record.  This issue has been argued before courts (and won).   
The documentation guidelines are just that "Guidelines" - (although the carrier won't believe that).

the CPT Assistant explains" it is important to note that these are Guidelines, not a law or rule.  Physicians need not modify their record keeping practices.(CPT Assistant Vol. 5, Issue 1, Winter 1995)

CMS has publicly stated that physicians are not required to use the "Documentation Guidelines"


----------



## 007CPC (Apr 23, 2009)

Lynncain said:


> Last week I posted a thread asking for help because my compliance officer had told me I do not have to wait for physician attestation  (I work at a teaching hospital) to bill a procedure.  As long as I informed the physician the E/M charge neede his attestation, it was okay to bill it before he added it.  After a meeting friday to help explain this to me I was also told not to hold a charge because there was no documentation.  Inform the physician  there is no documentation and then go ahead and bill it.  I asked my compliance officer what ever happend to "if it's not documented it didn't happen"  She said that it has been discussed in courts and challenged that just because it was not documented does not mean it didn't happen.  She assured me our corporate lawyers said we will be okay.  Help!! Did I miss some big announcement in the coding world that changed everything,  I need my job but this is crazy:



This thread "paints a perfect picture" of why I don't work in clinical-corporate-payer coding method (being copy boy isn't an accomplishment). Step by step coding books explain how to avoid situations that can end in sending you to jail and/or being banned from CMS. COs and JDs say it is okay to bill undocumented procedures; is that a way to help coders develop integrity among third party payers? The loop hool these people are seeing is a scam. ( I appologize for being bold). 

Has, anyone read the Coding Edge article in April issue written by anonymous: that is intimidating for someone with only 1-5 years experience.  

I do not trust Coding Managers/Compliance officers.


----------



## FTessaBartels (Apr 23, 2009)

*I DO trust our Compliance officers*

Chad Malek wrote (in part):  COs and JDs say it is okay to bill undocumented procedures; is that a way to help coders develop integrity among third party payers? The loop hool these people are seeing is a scam.  

I do not trust Coding Managers/Compliance officers. 

I beg to disagree. Compliance officers are hired specifically to ensure that the practice is in compliance with the law. If I've learned anything in my professional career is that "the law" is open to interpretation. 

CPT is owned/ copyrighted by the AMA. But CMS makes it's own guidelines as to what is acceptable documentation. And the local carriers are free to have guidelines that may be more stringent or otherwise differ from CMS as a whole. This doesn't even address the commercial payers who follow guidelines other than CCI. 

Is everyone who doesn't agree with CPT wrong? Or even worse, dishonest or a crook? 

I absolutely trust my Compliance department officers/staff. And our physicians do as well. 

Just because opinions vary from my own is no reason to distrust the entire profession. 

F Tessa Bartels, CPC, CEMC


----------



## dmaec (Apr 23, 2009)

nicely stated Tessa!  I agree! 

might I add....
Both the law AND the "guidelines" are open to interpretation - that's the thing with coding, not everything is "black and white and written in stone"...


----------



## dhuston (Apr 24, 2009)

I resisted the urge to immediately reply yesterday and instead offer this sentence from the AAPC's "About Us" section :

The American Academy of Professional Coders (AAPC) was founded in 1988 in an effort to ELEVATE THE STANDARDS OF MEDICAL CODING by providing certification, ongoing education, networking, and recognition. 

The capatalization is mine for emphasis and I think the message speaks for itself.

Diane Huston, CPC,RCC


----------



## 007CPC (Apr 25, 2009)

You medical coders are completely right!!!!!  I was directing my first post  to the initial post on the thread. I am going to assume, TESSA, you still work for MCW which is a good organization with a high morale among coders in the community. Lets just pretend that you ladies or men aren’t working at, what ever position you are working at. Some coding positions (at the low level) are made up of coding staff whose only concern is the over all financial success of their organization; these type of employers could care less if a medical coder does something wrong and gets blamed. Hope you medical coders know what type of employers I am talking about, if you don’t you’ve got it made.

I am not going to say anything else on crummy coding employers besides, if you harkened rigidly to my comment about managers and officers; you coders deserve the position your at.


----------

