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coding a bill - trans22

Posted: Aug 10, 2011

I have a question ?? I am a transcriptionist in a surgeons office. I transcribe the report, fax it if it needs to be faxed and it gets filed in chart. The billing takes place 2 to 3 weeks later for the service depending on how current the coder is. Now.... this is the question. The physician is very greedy and likes to have level III and IV charges. His gait keeper has decided that he was not dictating enough and not getting the higher levels and too many level IIs. So in the meantime she is giving them back with an extra line or two and billing for the higher code. No the record has been dictated, transcribed and just waiting to be billed. Is this legal? I feel like I am in a very difficult spot, I think it is upcoding and that is illegal, right? Please only knowledgeable coders respond!!

Depends - Knowledgeable Coder

[ In Reply To ..]
It kind of depends on what she is adding. Is it something he actually DID? If she's adding PE, did he really do that in the exam? Is it HPI? Did he really ask the patient about that and just forget to mention it when he dictated? And how would you know?

There is more than amount of documentation that goes into an E/M level. If someone has a cold, you cannot ever end up with a level 4 and probably not even a 3, because it is a minor, self-limited problem. You can add documentation and bump up the code, but the service won't qualify for that code. That is easily seen on an audit.

From your perspective, it would be difficult to tell what he did and whether the additions are warranted or are just there for upcoding purposes. Right now, you are seeing his original dictation as "the official what happened," but doctors can amend their reports later if necessary. If this is being done within 2-3 weeks, then the time frame isn't unreasonable.

I would stop worrying that you are in a tight spot, because you really are not. You are thinking you're seeing illegal upcoding, but it probably isn't that, even if the doctor is greedy.

If I were there, I'd probably be all over him to fix his dictation, too. That's what should happen in the long run -- he should fix his dictation practices so that change are no longer necessary after the fact.

I'm not so sure someone ELSE should be amending his dictation. But, maybe the gate-keeper has his permission or does this with his consent. He's the one who signs it, after all. If he's signing it, then he's responsible.

If he is doing something wrong, one of the Medicare audits is going to nail him. If his code utilization does not match the expected, they'll see it right away. Their computers monitor this.

My recommendation is that you avoid worrying about this. Just make the changes as requested. You're the transcriptionist, not the coder or the biller or the office manager, and those are the people who will get nailed on this. If the FBI came in to investigate, I'm sure they would want your computer, and you would have the pre- and post- changes in there for them to see. Right now, though, it's not possible to tell if anything bad is happening, so I'd chill and maybe sign up for a coding course so that next year at this time you can be the person advising doctors how to fix their documentation. :)

E/M coding - Anonymous

[ In Reply To ..]
There are on-line seminars and classes for physicians (and coders) to take to help the physician properly document a visit to optimize payment, it has nothing do with greed as long as they are including what they actually did. As an MT, the responsibility does not rest with you. Anyway, "E/M University" is a website that I have used and found helpful. They also e-mail the "Case of the Week," a self-test for coders and providers to make sure they do things properly.

Those aren't really coding courses but they might be somewhat helpful - sm

[ In Reply To ..]
The doctors I worked for used to go to those seminars and someone would just give them the codes that they should use for the exams they do most often. It's a short-cut and lots of doctors do it, but it's not anything close to being a real coder. It may not be a bad idea, but I just wanted to point out that you won't be a coder after attending a short course or seminar. You would be able to identify enough to choose from several codes in a doctor's office that only does a few procedures. That may be all you need, but it isn't coding. It's more like billing.

Courses - Anonymous

[ In Reply To ..]
I know they are no substitute for the real thing, but I found the on-line programs such as E/M University helpful when I was a student and still do the self assessments. I assumed that the person who did this already knew how to code. The OP stated that there were documentation issues at her office and it sounded like a small facility. I thought it might be a good thing for the provider to do to avoid having to make corrections in the dictated reports.

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