Good Day Fellow Coders,
I am doing some research regarding Billing and Compliance and have a general question for the Subject Matter experts in the field of Billing and Coding Compliance.
A claim is denied by an Insurance carrier as the CPT code does not match the age of the patient for a specific date of service based upn the patients age at the time of service. The physician is the person responsible for the Integrity of the CPT and ICD-9 Diagnosis code selected for this specific date of service via the Encounter form.
A Third-Party Biller within the Patient Accounts Department who is not a CPC changes the CPT code for the date of service based upon the patients age within the EMR for the specific date of service. The Third Party biller does not verify the correct CPT code selection via the EMR and or documentation from the Physician(Encounter Form) for the specific date of service. The Third Party Biller does not reach out to the Physician of record for the date of service to verify that the incorrect CPT code was chosen. The Third Party Biller just changes the CPT code without reaching out to the Physician of record, A coder within the organization, or the Supervisor, Manager or Director of Patient Accounts within the Organization.
If the Organization was Audited the Encounter form (Physicians Order) for the specific date of service will not match the Organizations EMR. Would like be considered Biling Fraud as what was documented does not match the service for what was billed??
I am doing some research regarding Billing and Compliance and have a general question for the Subject Matter experts in the field of Billing and Coding Compliance.
A claim is denied by an Insurance carrier as the CPT code does not match the age of the patient for a specific date of service based upn the patients age at the time of service. The physician is the person responsible for the Integrity of the CPT and ICD-9 Diagnosis code selected for this specific date of service via the Encounter form.
A Third-Party Biller within the Patient Accounts Department who is not a CPC changes the CPT code for the date of service based upon the patients age within the EMR for the specific date of service. The Third Party biller does not verify the correct CPT code selection via the EMR and or documentation from the Physician(Encounter Form) for the specific date of service. The Third Party Biller does not reach out to the Physician of record for the date of service to verify that the incorrect CPT code was chosen. The Third Party Biller just changes the CPT code without reaching out to the Physician of record, A coder within the organization, or the Supervisor, Manager or Director of Patient Accounts within the Organization.
If the Organization was Audited the Encounter form (Physicians Order) for the specific date of service will not match the Organizations EMR. Would like be considered Biling Fraud as what was documented does not match the service for what was billed??