Who does the Coding for Physician Services?

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Who does the Coding for Physician Services?

• Medical Billers and Coders

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The stakes are high. Coding drives revenue.
Coding compliantly is demanded of all practices.
Physician compensation is often determined by the
RVUs associated with the CPT code that is
submitted on the claim form. Health systems and
hospitals want to ensure that services submitted
under the group NPI are accurate and represent
what was done and documented? The real question
is who is responsible for coding physician
services? The medical provider or the coder? Who
gets the last word when there are disagreements
between what the physician coded and what the
coder coded isnt easily defined. There is no
free lunch here. There will be issues to identify
and problems to solve no matter which
professional does the coding.
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The answer is straightforward
The rendering provider is the only individual
authorized to select and responsible for
selecting a CPT code. CPT codes are physician
procedure codes, found in Current Procedural
Terminology, published by the American Medical
Association. The codes dictate the work done for
payment purposes. Legally, when a physician,
physician assistant (PA), or nurse practitioner
(NP) enroll in a Medicare, Medicaid, or
commercial insurance, the practitioner signs an
agreement attesting that accurate claims will be
submitted. The practitioner is responsible for
claims submitted under his/her NPI.
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As per CMS E/M guide, When billing for a
patients visit, select codes that best represent
the services furnished during the visit. A
billing specialist or alternate source may review
the providers documented services before
submitting the claim to a payer. These reviewers
may help select codes that best reflect the
providers furnished services. However, the
provider must ensure that the submitted claim
accurately reflects the services provided. The
provider must ensure that medical record
documentation supports the level of service
reported to a payer. You should not use the
volume of documentation to determine which
specific level of service to bill. The back of
the CMS 1500 form specifically states that by
signing the form the provider is attesting to the
accuracy of the codes submitted. The fact that
the claim is submitted electronically does not
change that attestation. That is, whether the
medical practitioner or a coder selects the code,
the practitioner is responsible for the codes
submitted on a claim form.
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In many private practices, the physician alone is
responsible for selecting codes, based on the
documentation, and this is done in the EMR, at
the time the note is complete. In some academic
practices or health care systems, and in groups
that are employed by hospitals, all services are
coded by a coder. There is one scenario in which
it would be appropriate for someone to change a
CPT code selected by a rendering physician,
advanced practice nurse, or physician assistant.
That scenario is when a certified professional
coder has been engaged to audit documentation and
the coder finds that the clinicians
documentation doesnt justify the CPT code
selected. Even then, the coder should tell the
clinician what changes are being made and why.
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Avoiding confusion between Provider and Coder
An internal compliance review will often identify
either service that needs review or providers who
need education or who need to have all of their
coding done for them. If coders are reviewing
notes and changing the codes after the provider
has coded them, there should be a mechanism to
let the administration and the medical director
know how frequently this is happening, and in
what direction the codes are being changed. Most
clinicians dont want additional emails every
time a code is changed by one level. Develop a
threshold for alerting administration, the
medical director, and the provider about when to
have a discussion and review. If 15 or 25 of
codes are being changed by the coder, that
requires a review and discussion. If the
disagreements cant be resolved internally, send
a selection of notes to an outside firm for
review.
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• Everyone in the practice shares the same goals of
  providing medical care for patients and
  collecting enough revenue to keep the doors of
  the practice open. In many organizations, coding
  is centralized out of the practice location,
  reducing the interactions and opportunities for
  asking a quick question and getting feedback. If
  thats the case, the coding department and
  practice management could set up regular
  meetings, even lunches to increase the
  interaction and improve the relationship between
  providers and coders. Set up regular meetings
  with providers to give them feedback about their
  coding and documentation. If there are services
  that are always bundled, tell the provider. If a
  procedure is missing something critical, such as
  the length of the excision, let the provider know.

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