# Educating doctors



## LLovett (Oct 26, 2009)

As a certified coder and educator I understand I am completely responsible and liable for anything I teach. I am hoping someone can help me with supporting documentation because I am being backed into a corner.

For the past year I have advised a practice that they are billing for services not supported by documentation. I have done everything in my power to stop these charges from going thru, unfortunately I am just one person and the vast majority have gone through incorrectly. Instead of fixing the billing to match the documentation they want me to "educate" the providers on how to document. I have told them what I feel and several others feel would be the easiest and simplest way. The issue is with PA assistant surgeon charges. The only indication that the PA was there is in the header of the op report. I have instructed them they need to document why it was medically necessary and who did what. They way I have instructed them to show who did what is by using terms like I, We, or mention the PA by name when they do something alone. 

This is not good enough. They want me to go thru an existing op report for each provider and reword it to support PA involvement and give this to them as an example of how their documentation should look. I have refused to do this for a year now. I keep telling them I don't know who did what and I am not willing to do that because I don't want them saying I told them they had to do their op notes that way. I have given them examples from other providers showing this type of word usage and I think it is a very basic concept to just start your sentence out with I, we or a name instead of just Next or Then.

I feel this is wrong but as I stated I am being backed into a corner. If someone has documentation to support how wrong it is to mock up existing documentation as an example of what would support the billing they want to do I would greatly appreciate it. I keep telling them they are approaching this backwards. They need to document what was done and code based on that, not change documentation to match coding. I don't have a problem helping them improve documentation, I have a problem telling them to improve it in a way to support incorrect coding practices that are already in place.

Thanks

Laura, CPC, CEMC


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## FTessaBartels (Oct 26, 2009)

*Private message*

Laura,
I'm sending you a PM.
Tessa


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## JMeggett (Oct 26, 2009)

*PA-C documentation*

I too feel that just stating at top of Op note that a PA assisted is inadequate.  But I've researched quite extensively and cannot find anything anywhere that states anything more than that needs to be in the documentation.  I even asked a reputable PA-C on the Ortho blog thru DecisionHealth and he said that just listing the Assistant Surgeon: (name)PA-C is sufficient.     Laura, if you find out anything more I would love to hear!  

Jenna


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## LLovett (Oct 27, 2009)

There are carriers out there that have very specific guidelines on what they want to see.

Example Blue Cross and Blue Shield of Alabama

http://www.bcbsal.org/providers/manuals/providerManual/guidelinesForAssitantSurgeonClaims.cfm

AAOS has a fairly nice document about it as well,

http://www2.aaos.org/aaos/archives/bulletin/aug06/coding.asp

"The surgeon of record is responsible for identifying the presence of the assistant surgeon or assistant at surgery and the work performed."

The above is from the prior link, they clearly state you need more than just their name in saying they must identify the work performed.

This is one for a health plan that is processing based on Medicare guidelines.

http://www.fchp.org/NR/rdonlyres/F0...AB80A/0/Assistantsrugeonpaymentpolicy9109.pdf

Medicare states the assistant has to actively assist, how else do you show that if not thru documenting what they did? There are 4 modifiers dealing with assistant surgeons. AS for non-physician surgical assistants (CMS states must be used in addition to the other modifiers) 80 for assistant surgeon, 81 minimum assistant surgeon, and 82 assistant surgeon when no qualified resident is available. 

I have posed the question to the providers, how can you separate out the 80 and 81 if you don't document what was actually done? They responded that there is never a minimum assist, I countered with apparently there is or they wouldn't have a modifier for it. 

I have been researching and banging my head on the wall over this for more than a year. Hopefully this info will be helpful to you Jenna.

Laura, CPC, CEMC


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## JMeggett (Oct 27, 2009)

Laura, thank you for those links.  The AAOS is the only one that my docs would value as an official source from those (since we're in Wa and don't deal with those 2 insurances referenced) and they feel the statement "*The surgeon of record is responsible for identifying the presence of the assistant surgeon or assistant at surgery and the work performed. In this situation, the assistant surgeon or assistant at surgery does not dictate an operative note. An MD or DO serving as the assistant surgeon will report the CPT codes for those procedures.*" is not clear whether "the work perfomed" is that of the surgeon or of the assistant.   Very frustrating to know that this should be done, but they'll only accept this if Medicare, AAOS or another official source clearly states "YOU MUST DOCUMENT WHAT THE ASSISTANT DID!".      I appreciate your persistence in educating those docs!
Jenna


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## RebeccaWoodward* (Oct 27, 2009)

You know Laura...I have to say...this is just perplexing...

It's in the best interest of your surgeons to properly document.  1) It provides clear rationale why the assistant is needed  2) It's extra reimbursement for the company as a whole...*if medically necessary*.

Again...I just have to throw this back into the *laps of administration*...  When the figures are presented after month end and adjustments have *increased* due to...let's say...lack of documentation for assistant surgery...someone has to answer for this...I'm sorry...this is blatant complacency, laziness, ignorance...take your pick


Just my two cents...(not to offend anyone)


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## ASC CODER (Oct 28, 2009)

Kudos to you for not "just doing what they want" I was in a somewhat similar situation. The Administrator wanted me to tell the docs what to say in their op note and "what not to say" so they could use an older code when what they were doing was a more specific code that the insurance company wouldn't pay. I never did it ) needless to say I left there after a year, they kept pushing me to "call the docs" I found a great place and they do things by the book which is how it should be.


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## Lisa Bledsoe (Oct 28, 2009)

I also had a similar situation where one surgeon wanted me to provide "exact precise wording" in order to use modifier -22 *and get paid*.  Thankfully administration fully supported me when I told him I could not put words into his documentation (mouth) since I am not in the OR and I am not the doctor.  I clearly laid out the requirements, guidelines, etc for him to follow...he just didn't want to own that.  I just know what auditors are looking for in order to pay at the higher rate and it must meet medical necessity.  Anyway, he has backed down and I feel fully supported by administration.


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## RebeccaWoodward* (Oct 28, 2009)

That's EXACTLY what I'm saying...Administration should be your support system...unless you're wrong...and in this case, Laura's *not*. Grant it...I don't have 500-800 physicians as some of you do but right is right and wrong is wrong. This is what we teach our children...WHY is this SOOO hard to communicate to those whose IQ's are off the charts???  Laura*...you have our support*...and I know that this may be little comfort in your world but you are respected amongst your peers...Stick to your guns!


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## Cyndi113 (Oct 28, 2009)

Laura, 

What about going directly to your provider reps/provider educators at one or more of the carriers and asking if they are able to come to give an "inservice" about documentation requirements? This puts the docs in direct communication with the carrier and possibly gives them the answers they are stubbornly holding out for. I know that Noridian (WA state) Medicare has an excellent resource in one of the reps. Her name is Tammy Ewers. Her email is tammy.ewers@noridian.com. She is always very helpful. She is also a CPC. If she can't help you, maybe she can point you in more appropriate direction.

It's worth a shot??
Good Luck and HANG in there!!


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## Lisa Bledsoe (Oct 29, 2009)

rebeccawoodward said:


> That's EXACTLY what I'm saying...Administration should be your support system...unless you're wrong...and in this case, Laura's *not*. Grant it...I don't have 500-800 physicians as some of you do but right is right and wrong is wrong. This is what we teach our children...WHY is this SOOO hard to communicate to those whose IQ's are off the charts???  Laura*...you have our support*...and I know that this may be little comfort in your world but you are respected amongst your peers...Stick to your guns!



Rebecca is absolutely correct!  Laura - you absolutely have OUR SUPPORT and our *RESPECT*!!!!


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## LLovett (Oct 30, 2009)

*Thanks Everyone!*

I greatly appreciate it!

As much as I hate to do it I am looking for another job right now, on the other side. I'm gonna try my luck on the payer side if I can. I have dealt with way too many providers and administrators that are not about doing the right thing. I thought I was at a better place now but the entire culture is starting to change. I'm seeing people that would have supported doing the right thing being demoted and downsized left and right and new positions are being created and filled with yes men and women with no experience in the job they are filling. 

Dark days ahead I fear....

I know payers do some dirty things as well having been on the receiving end for many years now but I'm good at what I do and I don't want to walk away altogether, figure I'll give it a try. 

I will continue to fight the good fight and do the right thing until I find something else.

It is hard being an ethical person in a "gray" world. Many times the gray areas aren't really gray at all, they are really just green. 

It is so wonderful to be able to come on here and see that I am not alone. Y'all don't even know how much I appreciate you!

Thanks

Laura, CPC, CEMC


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