Wiki Ethics Question

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LisaAlonso23

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How would you handle this scenario:

A dr presents you with a patient's EOB stating she was only reimbursed $100 for this claim and asks how it can be coded differently for a higher reimbursement.

I was taught that we're supposed to code what they do and only query doctors when necessary to code properly. Doesn't this cross a fine line?

I would love to hear how others would handle this.
 
This is not a good scenario. The best you can do here is show the provider how the documentation was used to assign the codes. I assume this is how it was done. The provider needs to be aware that how things are documented will drive the codes. Why did the provider feel this particular claim should reimburse more? Who decides what codes are selected?
 
Thank you for your input. That's exactly how the encounters/procedures are coded. I explained that the codes used are based on the documentation provided.

My office never had a certified coder, so I don't think my boss understands why I couldn't help this dr (we're a billing company). The dr said she was provided this information in the past, so it made me look like I was being difficult.
 
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If it's not documented, it DIDN'T HAPPEN. Simple as that. To do otherwise could get you in BIG trouble, should there ever be an audit!
 
This is an educational opportunity. The physician undoubtedly feels that the service provided is not reflected in the payment. Rather than discussing how to obtain higher payment, recommend discussing what the physician performed and does the documentation reflect this. If so, and the code assigned correctly reflects the documentation, then the payment is a matter of the physician's contract with the payer and/or a need for advocacy by physicians performing the service. If not, there is opportunity to discuss specific documentation gaps and/or correct code assignment.
 
Thank you. I don't want to do anything to damage the relationship we have with this dr. My superiors have put me in a terrible spot by allowing others before me to not only code but provide information to drs that's inappropriate. My predecessors were not certified nor professionally trained, so having coders who work within certain parameters is very new to them.

I really appreciate your input.
 
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