Wiki Surgery Coding by Fee Ticket, not Op Notes

[Wilson611]

Our Administrator is insisting that we have the physicians complete a fee ticket on the surgeries they perform and to enter their charges by the fee ticket alone. Currently we obtain the operative note and code from that.

My concern is that A) Charges will be missed, B) That if something is wrong, that the coders will be held legally liable

They are not currently certified coders but this is becoming a job requirement in 2015 here.

I would appreciate any feedback.

 

[jdibble]

I don't think that is appropriate billing! Unless the physicians are coders, things will be missed and worse yet, there could be incorrect charges submitted as well as unbundling of charges! Where I worked previously we had our physicians submit the codes for their procedures, then we audited what they coded, corrected the errors - which included unbundling, billing the wrong code per the documentation, and billing for procedures not performed. We then educated them on how they should be coding in the hopes of allowing them to do their own coding. After 3 years, most of them are still making the same errors and being audited and educated!

I don't think that is a good practice!

 

[Wilson611]

I Agree....

I agree but the Administrator will not listen....He stated that in the coders spare time she can "spot check". He wants her to enter what the doctor puts on the fee ticket and bill it out ASAP. His statement was "If the doctor gets it wrong it's their fault".

My concern and that of my coders is what is their liability in simply entering the data? I do not want them impacted legally because the administrator is being foolish.

 

[mitchellde]

Look up coder liability on the web also a few years back the AAPC published several articles written by an attorney with regard to coder liability. You should be able to search those in the Coding Edge. But the long and short of it is the coder is also liable for any information and codes she/he submits on a claim. I have been to court before for claims and the court sees the claim as the same as an ate station statement. The coder is attesting to the information on the claim as being equal to what is documented in the note.