Wiki Changing Diagnosis or CPT Codes

[amanda.vanhouten85@gmail.com]

I am trying to settle a dispute at my work. We have a handful of people who say only providers can change CPT codes or diagnosis codes that truly fit the documentation of what services were provided, etc. etc. An staff person had "googled" and supposedly found an article that states that anyone that is a CPC can legally change a diagnosis or CPT code. I hope this is not confusing. Bottom line is, I am trying to find out who is legally allowed to change codes

 

[cgaston]

If providers were the only one who could select a code we wouldn't need CPCs! This must be your company policy.

Everywhere that I have worked allows the coder to select the most appropriate code to bill. My providers are notorious for selecting a diagnostic colonoscopy code when the report documents that they removed a polyp. I would not have to consult with anyone to change it to the correct code, but you should follow your company's policy.

 

[sxcoder1]

I agree and change both all the time if they are incorrect. I have also had coworkers say we are not supposed to change a dx code, but that does not mean that we cannot change an incorrect dx code picked by the provider. We can't change the diagnosis, but we can of course change the diagnosis code to match the provider's documentation. And the providers pick the wrong CPT codes all the time.

 

[amanda.vanhouten85@gmail.com]

I agree and change both all the time if they are incorrect. I have also had coworkers say we are not supposed to change a dx code, but that does not mean that we cannot change an incorrect dx code picked by the provider. We can't change the diagnosis, but we can of course change the diagnosis code to match the provider's documentation. And the providers pick the wrong CPT codes all the time.

So if anyone, not CPC certified, feels like there is a more accurate code for the diagnosis, are they legally allowed to change it. My assumption was only those who are CPC certified are allowed to change it?

 

[thomas7331]

So if anyone, not CPC certified, feels like there is a more accurate code for the diagnosis, are they legally allowed to change it. My assumption was only those who are CPC certified are allowed to change it?

The laws that govern coding are only concerned with whether or not the claims are accurate - they are not concerned with who put the codes on the claims or whether or not that person was certified. Physician practices and other healthcare organizations are responsible for submitting accurately coded claims supported by documentation, but how they accomplish that is left up to them and their managers or owners. If an organization chooses to only allow physicians or only certified coders to make the final coding decisions as a policy to support accurate coding, they are free to do that or not, and must accept the risks and consequences that are involved in that choice. It is an internal and operational decision, not a legal requirement.

 

[pscanlan]

I agree and change both all the time if they are incorrect. I have also had coworkers say we are not supposed to change a dx code, but that does not mean that we cannot change an incorrect dx code picked by the provider. We can't change the diagnosis, but we can of course change the diagnosis code to match the provider's documentation. And the providers pick the wrong CPT codes all the time.

Generally, I don't have any qualms about changing a Dx code that a physician provides, so long as I'm basing it on some documentary evidence from the medical records. That is substantially different than actually changing the diagnosis. Sometimes the codes don't line up exactly with what the patient has, or what was performed - unspecified and NOS codes exist for these situations. Not all medical diagnoses will translate directly to a diagnosis code, which is exactly why coding jobs exist - to choose appropriate codes.

When a provider doesn't indicate a code, just a written diagnosis, it is usually entirely in the coder's purview to select the closest, most accurate code to the written description given. I don't think I'm alone in my experience when I say that most providers have limited knowledge of the ICD-10 code set (to say nothing of CPTs), despite their extensive knowledge of their specialty. I had one provider (in his 60s) who - just last year - was still writing ICD9 codes on his billing cover sheets. What a headache. Of course I changed them, no carrier would take ICD9s at that time.

The laws that govern coding are only concerned with whether or not the claims are accurate - they are not concerned with who put the codes on the claims or whether or not that person was certified. Physician practices and other healthcare organizations are responsible for submitting accurately coded claims supported by documentation, but how they accomplish that is left up to them and their managers or owners. If an organization chooses to only allow physicians or only certified coders to make the final coding decisions as a policy to support accurate coding, they are free to do that or not, and must accept the risks and consequences that are involved in that choice. It is an internal and operational decision, not a legal requirement.

This is my understanding as well. The provider whose name is on the claim is ultimately responsible for the accuracy of all information contained therein. If the provider take that to heart and want all changes to claims run past them, that's certainly one way of doing things. I don't know how every company works, but the couple that I've worked for did not require any such physician review before claims could go out. That seems very... time consuming. But anyway, there are no real "legal" limits to who can change claim info - it comes down to who the provider authorizes to do so.