Wiki Push Back on How Something is Coded

[allison_w_99]

In our practice, there has been push-back from billers and managers on how something has been coded by the certified coders. In nearly every situation, the person questioning the coding clearly has no understanding of how to apply codes but they are still skeptical of what we tell them and won't accept it. If it is not obvious to me if there is a coding error on a claim, I always review the documentation, check the descriptions in CPT, look up any unfamiliar terms in a medical dictionary, and check the edits to verify the documentation supports the coding and there are no bundling issues. It is very frustrating and actually insulting when people who are not qualified to apply codes constantly question what you do and treat you as if they don't think you know what you're talking about. They are assuming it is a coding issue because they can't figure out what's causing the claim to reject.

I think this is just because they have an old style way of doing things and management may not fully understand our qualifications; therefore, credentialed coders are not given much independent authority that pertains to their duties. Have any of you experienced this and how do you handle it?

 

[PLAIDMAN]

unfortunately I am going to have to tell you to get used to it.

I have been coding for 15 years and I still get "are you sure"

I would recommend making yourself a reference book with copies of your rules/regulations from reliable/respected sources...this may include copies of pages directly out of the CPT book....so you just provide anyone with questions this info.

DO NOT take it personal....its not that they don't believe you...they just don't understand...and it doesn't help that the ins. companies tell them "its coded wrong" which really translates to "its not a covered benefit"

I have found my "reference" book extremely helpful...and it has also "proved myself" to management

 

[SDAlward]

I get that all the time. I've been a coder for 1 and a half years and there are people in authorizations who have been there much longer who question me all the time asking "are you sure?". What they really mean is "that's not a covered diagnosis". People just want to twist and make up stuff to get things paid these days. It's definitely insulting because I studied hard and went to school for coding and these people have no credentials. I'm sure it happens everywhere though, sorry!

 

[nsteinhauser]

PLAIDMAN is spot on. I've been coding for 14 years and it is an almost daily part of my job. From conversations with doctors regarding code choices. To working denials with the payers - who don't want to pay for claims and increasingly shrink 'covered benefits.' To educating the patients who were told 'it was coded wrong' by the payers. To educating providers' offices who don't understand the rules and regulations of coding and may not understand anatomy. To defending your choices to the fault finders in your office who spend inordinate amounts of time trying to find others' mistakes and then point fingers at the coder for 'making a mistake' when you were actually coding it correctly. To then educating the manager who has to appease the fault finders and you need to explain the operative notes (with an anatomy lesson) and defend your choices of what the most appropriate codes were to use and why. DOCUMENTATION is critical here. Why should anyone believe your word over someone else's?
Defending choices of codes has ended up taking me an incredible amount of time over the years but it has made me a better coder. It's part of the job.
Like PLAIDMAN said - start collecting data/references/examples from reliable sources. CPT book, CMS publications, payer publications, CPT Assistants, publications and references from the AMA and other medical societies, and references from coding organizations like AAPC, AHIMA, The Coding Institute, etc. I have a number of reference books I've made (by collecting pertinent materials) and then use these documents to educate and then defend my choices of codes.
Don't take it personally. Depending on the culture in your particular place of employment, the 'coder' may be the lowest man on the totem pole and you know what rolls downhill. Become the most accurate/ the best coder you can possibly be with documentation and references to prove your choices. Invite any chance you can get to be audited by a respected source - to learn more and also to have more references for your defense.
Your qualifications may mean a lot to you but in the day to day world of medicine, coding is not a black and white science. Educating and defending are a part of the job. You may never get ANY independent authority, depending on who you work for. But that's ok. Step back, take a deep breath and enjoy the process. Use this forum. There are so many wise and wonderful coders out there. Hope this helps.