Wiki Coders/Billers changing E&M codes

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sjcarlile07

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I have looked through many threads and the only one that I can find that addresses this issue is from 2007. Since that was 8 years ago and we know how things change so often, I would like to have current clarification on billers/coders changing E&M (really all) codes based on the physician's documentation. Is this allowed or not??

Do we still query physicians when we need further clarification about a code when the physician codes one thing but the documentation may support something else?

I am getting pushback from my corporate office stating that only the physician or certified coders can make those changes but everything I read states coders/billers are allowed to change the codes when basing it on what is documented in the chart. :(
Thanks

Stacy
 
Currently there is no law or regulation that states only physician or certified codes may assign codes. However this could be a corporate or office policy. Codes must match the documentation, and as long the one assigning the codes is reading the documentation then it is compliant that they change whatever was assigned as code by the physician to the code that matches the narrative note.
 
As other responders have noted: no law against it but it may be against company policy. In that situation, if somebody that is not a provider/CPC finds a coding error, maybe you should bring it to whoever CAN change it. If it is something that happens often, and they ignore it, that's fraudulent, and they don't want to get caught up in all that. You'd be doing them a favor :)
 
Even though it has been quite some time since the beginning of this thread, I was presented with this same question today. I was under the impression that coders could make suggestions as to which codes would work better, but it was up to the physician to approve it. But either way, shouldn't the physician make an addendum or amendment in the pts. chart noting the dx coding change? Documentation has to match the coding, so shouldn't the physician be involved in this process somewhere?
 
Codes must match the documentation not the other way around. There is no need for the provider to note a code change as long as the code on the claim is supported by the note. The coder may not assign or make suggestions for codes clearly not supported in the document.
 
CODER'S CHANGING PHYSICIAN'S E&m CODES WITHOUT FIRST DISCUSSING IT WITH THE PHYSICIAN

I am seeking printed documentation/guidelines regarding whether a coder may change the level of a physician's E&M code without first advising the physician that the level they have assigned is not supported and/or asking the physician if they would choose to write an addendum or if the code can be put through at the lower level. The majority of these claims are Medicare, but not all.

Any feedback or assistance on where to begin finding this documentation would be greatly appreciated!
 
DOCTORS DON'T CODE! There are doctors who have picked up the habit of choosing their own codes, but they are almost invariably ill-trained for the task and tend to code wrong.

The way it's supposed to work is that the provider documents the diagnosis and services (in words), and the coder chooses the code that matches those words. It's not up to the provider to "decide" what level E/M he did. The coder decides, based on very specific specific guidelines for coding what the provider documented in the note.

So the question: "Do we still query physicians when we need further clarification about a code when the physician codes one thing but the documentation may support something else?" means that your corporation is approaching coding altogether backwards. You, as the coder, should be choosing the code to that best matches his documentation. The provider should not be "choosing" codes.
 
There are no regulations governing who can or cannot choose or change a code or what process has to be followed to do so - the only rule is that the code must accurately reflect what is documented. So it's unlikely you will find any official documentation or guidelines that address these questions. Medicare and commercial payers do not really care whether the coding was done by a physician or by a coder; they only care that it is the right code so that the payment is correct.

It's really up to each provider organization to decide how much of resources to invest in coding, and what processes to put in place in order to ensure quality and mitigate the potential risks of incorrect coding. Some physicians and non-coders do in fact know how to code very well within their specialties. From a practical perspective, simple coding scenarios can be done by anyone with minimal training and do not require a certified coder whereas other types of services really do need something with the training in order to ensure accuracy. It's reasonable and understandable that organizations will not want to go to the expense of using coders for every single service that is billed.
 
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The doctors in my past experiences have chosen the wrong E/M service level as well as butchered the definition of new versus established about 75% of the time when they circle the E/M codes on the fee tickets. The error rate on diagnoses are also on the same level when compared to their dictations and/or chickenscratch reports.

Peace
@_*
 
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