Wiki Who is responsible for the code? Provider or Coder

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jmartin106

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We have a new billing company that keeps changing the codes selected by our providers, which is causing dissatisfaction among our providers. I think we may stop using them, but I want to know who is legally responsible for the codes on the claims being submitted, is it the provider or the coder? Is there any official documentation for this?
 
jmartin106 said:
We have a new billing company that keeps changing the codes selected by our providers, which is causing dissatisfaction among our providers. I think we may stop using them, but I want to know who is legally responsible for the codes on the claims being submitted, is it the provider or the coder? Is there any official documentation for this?
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What changes are they making? Do you have any examples?

If your provider is putting diagnosis codes on the claim that have Excludes1 conflicts or if the CPT codes have NCCI edits, the biller won't even be able to submit the claim without fixing the issue. It will get bounced back from the clearinghouse.
 
Is what they are changing it to the correct coding though? :)
Just because something is changed and the provider doesn't like it is not enough. It would require auditing and checking.
The provider is responsible for their billing and coding however, there is also responsibility on coders, billing and coding companies, etc. It depends on the extent and what it is.

oig.hhs.gov

I. Physician Relationships With Payers

oig.hhs.gov oig.hhs.gov
 
amyjph said:
Is what they are changing it to the correct coding though? :)
Just because something is changed and the provider doesn't like it is not enough. It would require auditing and checking.
The provider is responsible for their billing and coding however, there is also responsibility on coders, billing and coding companies, etc. It depends on the extent and what it is.

oig.hhs.gov

I. Physician Relationships With Payers

oig.hhs.gov oig.hhs.gov
Click to expand...

Exactly. Providers are responsible for their claims, but billers and coders are also responsible for the information they are submitting.

At the recent Healthcon Regional in Philly, I attended a session about billers and coders potential legal liability, presented by Robert Liles of Liles Parker. It was fascinating, yet also a little scary to see the specific citations of the legal risk that we bear too!
 
Providers are responsible for accurately documenting what happened during an encounter. Coders are responsible for translating that documentation into CPT, ICD-10 and ASA codes (used in anesthesia coding). Providers most often do not benefit from selecting codes, as they are not familiar with the coding conventions and/or guidelines that certified coders must abide by. If the billing company is changing codes and providers are not happy with this, request the billing company annotate when and why they are changing codes for about one week. Then, review their findings with the providers. Most often, codes are changed for the right reasons that providers are unaware of.
 
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