Wiki A questionable directive???

[jplouffe]

A question was asked at this year's AAPC convention in the Legal Trends general session. I would like to get some feedback from the forum on this question as I feel that it could affect many coders.

The question was in regards to a "coder's" protection when a directive was given that the coder is to not change the level or CPT code (E&M) when the documentation does not support the level selected by the physician/provider.

The response from the panel and the attendees was "why" would someone have a coder look at the documentation and not have them ensure that the coding supports that documentation. The overall consensus was that if the coder is the last set of eyes on that documentation, then they should make the correction and educate the physician/provider accordingly.

I strongly feel that as a Certified Coder, you should not knowingly send out a claim that the CPT code/level is not supported by the documentation. However, if you are given a directive as the one above, how would you handle this?

 

[mitchellde]

You have a couple of choices, one would be to follow the directive but know that you knowingly submitted a claim that is possibly not supported by the documentation and you are liable for any penalties as a result.
OR you can go ahead and review the documentation for verification and risk the inevitable.
OR you can refuse and force someone else to submit the claims but then again you are still liable as you know the claims are submitted without verification.
OR you can resign and seek employment elsewhere.
There is no substitute for reading the entire note. I teach this at every class and yet no matter where I am no matter who attends more than half of those submitting claims never read the document, there are a huge number that will take the EHR code suggestions as fact and just use those.
We call ourselves coders, then we need to perform the job of coding, not data entry.

 

[Cyndi113]

I definitely agree with what Debra has posted above. Here is a copy of the False Claims Act page (http://www.justice.gov/civil/docs_forms/C-FRAUDS_FCA_Primer.pdf): The knowledge requirement
A person does not violate the False Claims Act by submitting a false claim to the government; to
violate the FCA a person must have submitted, or caused the submission of, the false claim (or
made a false statement or record) with knowledge of the falsity. In § 3729(b)(1), knowledge of
false information is defined as being (1) actual knowledge, (2) deliberate ignorance of the truth
or falsity of the information, or (3) reckless disregard of the truth or falsity of the information.

I hope this helps,