Wiki Hard Headed Provider, Messy Situation !!!!

[mmoorer]

Hello everyone,
I need your opinions please. So, I am billing for a family practice physician and I noticed some coding that I felt was inappropriate (from what I have experienced in my billing career thus far). I tried to explain to this provider that it is NOT appropriate to append modifier -25 to any level E/M being billed with a rapid strep (87880) if the only reason/condition for the encounter is for a sore throat/pharyngitis. Also, I proceeded to tell this provider they were billing wayyyy too many 36410, which I proceeded to tell them the code is only intended for difficult blood drawing where the veins are not easily accessible; I recommended they use 36415 for a routine blood draw if that is what is documented.
This provider bluntly told me I did not know what I was talking about and to continue using the same codes !!!!!
Needless to say I am furious and I told them I was not comfortable doing this. My intuition is telling me to notify this provider I will no longer be providing billing services for them.
What do you guys think about this sticky situation ? Am I wrong or right?

 

[CodingKing]

Can you easily fire him as a client? Being new at this that would be my first thought but, I would feel bad sticking someone else in the same situation. Have you shown him the guidelines? Maybe some documentation showing him what the fines could be under the Federal False Claims act?

 

[mitchellde]

You say you are billing for this provider, my question is... Are you reviewing the documentation befor submitting the claims? Do you know that the documentation does not support these codes? Without a review of the documentation there is no way to know if the cides are correct or not. If you review the documentation then you have the responsibility to bill the codes supported by the note not necessarily the cides the provider submits.

 

[thomas7331]

Yes, agree with Debra above, you can't judge coding just based on billing patterns, you have to look at documentation primarily. Now if the documentation truly doesn't support codes, then you have an opportunity to present this to the provider in a positive way by showing that they are potentially putting their practice at risk and that you are trying to protect them. You can also try to find opportunities where their documentation is strong or actually might support a higher charge that they might be missing. If you put it together in a package of feedback that has strengths and weaknesses both, you get a better response from providers than if you just point out what they're doing wrong and put them on the defensive.

 

[mmoorer]

All points noted and advice taken. Thank you guys for the feedback, and yes I have reviewed the documentation and it does not support the coding. I really do not feel comfortable with the billing, but the major problem is the previous biller before me did not point out any of these errors so now I look like the bad guy. I think I will take all of the advice above and gather some supporting documentation to address him with (even though I doubt the provider will even bother to look at it), I didn't realize the way I came across was so harsh until you guys pointed it out and I appreciate it. I will try to take a more subtle approach and if that still does not work I will have to part ways.