Medical Billing Forum

Coding => Coding => Topic started by: Michelle1965 on August 29, 2014, 06:00:24 AM

Title: Coding Issues
Post by: Michelle1965 on August 29, 2014, 06:00:24 AM
 If I start my own Billing Company who is responsible for the proper Coding, Physician or the Billing Company?  I am currently an employee for a specialist, and I am a CPC.  Sometimes when I present the provider with the guidelines on Coding I feel they don't read them. They have told me to bill it, and if it gets denied then they will worry about it.  It does upset me, because I do my research, and read all of the guidelines.  I feel like they don't trust my decision, and getting the denial would be proof to them I guess.
I do feel like I'm wasting my time, and knowledge that I have. If they were to ever get audited as long as I have proof that I told the provider about it am I protected, since I'm a CPC, and if not can I refuse to bill it out or do I still have to do what the provider is telling me to do?
Title: Re: Coding Issues
Post by: PMRNC on August 29, 2014, 07:24:04 AM
It's a grey area... the law says that if you KNOW of something being billed improperly you are held just as responsible.. YOU know. It wouldn't be any different if they came to you and told you to bill something that never happened and don't worry about it they will take care of it when it's paid or if there is an audit. Once you are aware of a situation in which you should know is improper and you do know, then you have to tell the provider you are the one billing it and you are just as responsible as he/she. My liability as a billing company is the same as yours basically even with you being an employee. If I know something is not right and I bill it anyway, I've become an accessory in the eyes of the law. Not only that but I have a legal responsibility to report it in many situations, my compliance plan states as much. Now I can understand that anyone would not want to argue with the boss, however I think you need to ask yourself if it's worth the risk if the practice gets audited, your the first person on the chopping block. 
Title: Re: Coding Issues
Post by: kristin on August 29, 2014, 06:36:49 PM
Agree with Linda 100%. To add my two cents:

It is ALWAYS the provider's responsibility to choose the correct codes/dx's, even if they have a CPC on staff. If you the CPC abstract the correct codes/dx's from the medical record, the provider still needs to ultimately agree that what you have chosen is correct. Because it is their name/signature on the CMS-1500 form, not yours. But if YOU know that you are being told to fudge guidelines, or worse, and you do so, you will also be held responsible.

Now if you start your own company, and you are just billing, and not coding, and have no access to treatment notes, it becomes more difficult, because basically you are being given a superbill with everything selected for you, and you have no way of knowing if it was done or not, or if it is at all accurate. You can add certain modifiers, and arrange the charges for maximum reimbursement but that is about all you can do without consulting with the provider. If there is anything else that you need to do, you need to talk to the provider. For instance, I know when a provider I bill for means to link a certain dx to a certain CPT code, but they link a different, incorrect dx by accident. I don't just change it, I notify the provider as to what is wrong, and they give me permission to correct their error.

Sometimes you DO have access to treatment notes, if you are using their EMR/PM system, but unless you have been given permission to look at the notes, you are again taking the provider at their word that they have done what they have billed for. Because you are a CPC, you may take on a client who not only wants you to bill, but code also, or to check their coding for them. I do a lot of that for all the providers I bill for, because many of them are "newbie" docs. I explain to all of them that while I am not a CPC, I do have 19 years experience in my specialty, and I can help them in "learning" what they need to know about code selection, LCD's, etc., but that THEY are ultimately responsible for sending me accurate claims to bill.

That said, I have also had to quit billing for three docs over the years who I quickly figured out did not know what they were doing, were definitely committing fraud, even if it was due to ignorance, and they refused to listen to me about what was the correct way to do things. I flat-out refused to send their claims in, and walked away. You have to be prepared to do that. And you WILL figure out quickly if something is fishy with their coding, regardless of whether you have access to treatment notes or not. I had one doc who had three locations, and he was billing PT codes that required constant attendance by the doctor.  I figured out in the first week of billing for him that he was having his untrained staff doing the PT, because while he was in one office, he was billing for PT done at the same time in his other office 30 miles away. I immediately confronted him, and was told "my other biller had no problem with this, and that is the way I have always billed it". He refused to acknowledge that it was wrong, so I walked after one week.

Before you take on a client once you get your business going, be sure to have a strong compliance plan in place, an iron-clad contract, know what the provider will expect from you and vice versa, and be prepared to walk away if you have to at any point.
Title: Re: Coding Issues
Post by: Michelle1965 on August 30, 2014, 05:53:52 AM
Where can I go to learn how to put a compliance plan together and an iron-clad contract?  Any resources would be greatly appreciated.  :)
Title: Re: Coding Issues
Post by: kristin on August 30, 2014, 12:04:17 PM
I am sure there are some resources here, for a start. You can generally do some research on the internet also, see if you can find examples of contracts and compliance plans. I know they are out there, because I researched them myself for a billing company I worked for once. That should give you some idea of what you need for yourself.

I would use an attorney who specializes in healthcare when it comes to actually drawing up your contract. I know people who have just used simple one/two page contracts they found on the internet, and they regretted it down the road, because the contract didn't cover nearly enough of what they needed.
Title: Re: Coding Issues
Post by: Michele on September 01, 2014, 07:25:41 AM
You can find some good info by researching on the internet as Kristin said.  We also do cover writing a compliance plan in our contract book.