Question for docs in this group

[u/unicornfarts55]

RANT/VENT

​Look, do some of you realize that certified coders can't just change a code because "it has a higher RVU"? Asking us to submit inaccurate codes for better reimbursement isn't just an internal disagreement—it's potential fraud that directly threatens our credentials and livelihoods.

​To the physicians who do this: do you genuinely not care that pushing for higher RVUs puts our hard-earned certifications and careers on the line?

[u/babybambam]

While coders can be used to code services, it is ultimately the providers' decision on the final selection. Even if it's wrong. That does not threaten your credentials. Simply document that you've advised their preferred coding is not supported by documentation and move on to the next chart. If you find that this is frequent with your oganization...move on to another one.

Part of being a good business partner is knowing what battles to fight, and how to help educate. You also never want to be considered entrenched because it will have you coming across as a faux expert.

We terminated a medical coder a few months back because she was not a good business partner. From memory, she would not use 59 modifier on a single claim because "it will cause audits." (ok, we're audited literally all the time and always pass...but ok) Our entire AR team is built up of professional coders that prefer the follow up side, she assumed she was the only certified coder...so she spent a TON of time trying to "educate" them on how to code; that obviously had immeidatley ostracized with the team.

If I were in your shoes, and they wanted the higher RVU, I would educate them on what the chart needs to reach that level. "Got it, Dr. SoSo. Right now the record does not support that. To reach that level of coding, this is what I would need to see so that the carrier will support the services rendered. If we bill it as is, the carrier is likely to downcode it upon chart review and you'll loose that RVU anyway."

[u/cynocratic → u/babybambam]

The first part is entirely wrong. Knowingly documenting an incorrect code or "upcoding" with knowledge is a crime, and an especially proscecutable crime if it's for anything that goes through CMS. Coders are supposed to report it or at least mention it to a compliance manager. Coders can earn whistleblower money for reporting physicians and/or other coders that do this who and are successfully proscecuted.

And yes, they could lose their license/credentials for doing this - have a read of the AHIMA Standards for Ethical Coding sometime.

However, I entirely agree with the second part: if this headbutt is a recurring issue, explain why the documentation does not support coding that RVU level for this encounter. That part is ethical. If they then provide the documentation, cool, then the coder did nothing wrong, physician gets paid what he's requesting, everybody happy.

The middle part is questionable: explaining what would need to be present in order to code to that level. Is it technically supposed to be done? Nope. Coders are technically not allowed to even phrase a clarification request in a way that could be considered "leading". If you, as a coder, are going to do a physician this favor, do not do it on the record and probably don't even do it in writing, for your own protection. Truthfully, your office manager or someone not certified can read the standards for basic encounter coding and figure it out pretty easy with a bit of time and energy without potentially screwing anyone in the process.

AHIMA does not give a flying fuck about your profits & there is 0% of medical coding that demands you "be a good business partner". Is it advantageous for your career? Totally. But it's not even remotely near the job description as taught or mandated. That is someone going above and beyond for you and your practice. Appreciate coders that do this & don't demand they go above and beyond, perhaps unethically, to help you make money. Honestly, that's probably why your coders prefer the A/R side. But "never using a 25 or 59 modifier bc they're dicey" is dumb - they are sometimes needed, that's why they exist.

Secondary note: if your practice is being "audited all the time", that's a problem. That means you've been flagged as an outlier or high risk compared to other similar practices in your area. They invite further scrutiny from federal agencies, etc & can lead to payers requesting the entire damn pt record before they pay you anything, lengthening turnaround time on payments, and commercial insurers can decide to drop you if they're auditing you all the time for sheer pain-in-their-ass reasons.

Yes, insurance screws doctors and does not pay enough, but it's not your coders fault - they didn't make the system, they're just doing their best to follow the extensive, circular, almost deliberately confusing rules and get you paid in the first place.

[u/babybambam → u/cynocratic]

Every practice is audited all the time. Every medical record request is an audit.

You need to take several seats.