CODING CORNER: Develop Keen Eyes for Coding Mismatches

Veering off-course from the op report can land you in hot water

You’ve been coding straight off the op reports that the physician dictates immediately after completing surgeries--but you’re getting denials because your code choices don’t line up with what the physician’s billers reported. Here’s how to take the bill by the horns and keep coding correctly at the same time.

Cover Your Assets
Regardless of what the payer might say, you should code what you see on the op report, because according to the documentation, what’s recorded is what happened. In case of an audit, that information will be the only defense of your choices--the codes the physician’s practice reported won’t mean a thing.
“As a coding professional, you must apply the appropriate coding rules and code with the documentation that you have in the medical record. You will be coding accurately, and if you are audited by any organization, the information will be there to verify what you have coded and billed,” says Ginny Mansfield, BS, CCS, coordinator of coding and data quality at Clarian Health in Indiana.
Matching your coding with the physician’s office can be risky, because its code choices may not be correct, says Robin Richards, CCS, compliance specialist at Mountain States Health Alliance in Johnson City, Tenn. “Let the office worry about itself. The procedure code you submit must be backed up by documentation upon audit--that is all you need to worry about,” she says.
 
Here’s why: In some cases, physicians’ offices have either coded incorrectly or chosen codes that match their resources expended (but not the facility’s). Many physician practices don’t have coders on staff, or they bill directly from the physician fee schedule, which gives them a higher margin of error.
Make a Phone Call
You may benefit from contacting the physician’s office to discuss the chart and find out why it chose the codes it did. For example, one reason for the discrepancy may be that after the surgery, the physician supplied her office with additional documentation (that you didn’t have available when selecting your codes).
In that case, you can always ask the physician to send the necessary addendum and, if appropriate, you can change your code. If the doctor doesn’t send the added information, have the facility discuss the issue with her.
Secure backup: Don’t change your codes to match the physician’s without proper documentation, says Christopher Felthauser, CPC, CPC-H, ACS-OH, ACS-OR, PMCC coding instructor and consultant for Orion Medical Services.
“If an insurance company won’t pay my claim because mine doesn’t match the surgeon’s, I verify with the op note then contact [the surgeon’s] office,” Felthauser says. “I usually have to [...]

- Published on 2006-02-24