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Coding Corner

Confessions of a Payer Coder

I admit I have gone to the dark side: I work for an insurance company.

I used to work for doctors and ASCs, so I know many people think payer coders are all ill-trained, uneducated idiots working off a script, with no knowledge of the real world of medicine. Actually, we are as well trained as coders elsewhere, and we also have to know the billing and legal components as well as or better than the coding.

Some very simple things may cause me, or someone like me, to take a special interest in the goings-on at your facility - this isn't the kind of interest you want. I can't speak for every payer or payer coder, but I can give you some insight into the things that you may want to watch for in your billing practices.

Billing Forms
Do you know which payers will take a CMS1500 and which ones want a UB04? If you don't, you should find out. If you're billing to an automobile liability payer - especially in Florida or Pennsylvania - read your state statutes closely to find out which form to use. I see UB04s submitted with a type of bill indicating outpatient surgery center, when the statute clearly states that a CMS1500 is the one to submit for auto carriers. That means that your bill has to actually cross my desk to be manually priced. If you consistently do this, I will get used to seeing your facility name and will likely start a profile on you for future reference. If you had submitted it correctly the first time, the claim would have gone through the automatic channels and not have had to be managed as an exception.

Diagnosis Codes
You have undoubtedly heard about diagnosis codes being the justification for medical necessity for the outpatient world. But what about using the same codes as the surgeons, instead of the same codes as the referring physician? As a payer coder, I look at all the diagnosis codes for consistency. If you apply a non-specific diagnosis as the reason for the encounter, I will very likely have to determine the validity of that bill submission. Why would you have a non-specific code such as "diffuse pain" or "sprain" and still need to be seen in an ASC? If the codes aren't clear, or they're symptom-related only, it's likely that your bill will be suspended pending a pre-payment documentation review. Try to take the most succinct codes you can get, with the most descriptive (and correct) records from your providers.

By this time, I will have seen your bills cross my desk a few times, and I'm starting to see that your records are substantively the same each time. Does each patient really have the same condition each time? Does the doctor really dictate the exact same phrases each time a patient with this condition is seen? If you have an EHR, there is a good chance that your narrative is identical for each patient. While most providers find this easier for routine procedures, be aware that this is also how less reputable providers sometimes try to justify their overcoding, unbundling, and excessive utilization.

Seeing the same things over and over for different patients may suggest to me that your facility needs to be investigated with a clinic inspection (in states where this is allowed) or a further record review. After all, if you're doing this for patients under my payer, are you doing this for all your patients?

Business Licenses and Inspections
Since I have now decided that your bills are being managed as exceptions, and you keep submitting records that look the same on the wrong forms with codes that I have to condone or refute, I now want to look at your business license and practices.

  • How many people are listed on the ownership of your facility?
  • How long have you been in business?
  • Are you linked to any other practices?
  • Have you been inspected by the local board of health, the local Medicaid agency, or Medicare MAC lately?
  • What happened in your last HEDIS audit?

Most of this is public record, and if I'm really suspicious, I can get a special authorization to request similar records from other carriers. In the state of Florida, most of this information is found by your tax identification number, which is listed with the Division of Corporations. Not all states do this, but many have some variation on the theme.

Were you or your accounts receivable representative nasty when calling to ask about payment? A limited number of people are available to answer the phone about claims at my office. The people who are nasty tend to get called back last, and no amount of threatening will do much good. We hear about being sued so often that we have a department that handles nothing but lawsuits. Yelling at me, one of my teammates, or the claims adjusters will not help your case; it will likely make the situation worse.

Suppose that you make a mistake at a later time, for example, someone keys $0010 instead of $1,010 as a charge amount, and you want to get paid the remainder. If you're mean, you likely will be told you're not getting the benefit of the doubt (unless your state law requires it), no matter how many times you appeal it.

Did You Really Do Anything Wrong?
Very likely your facility is clean, efficient, and you have excellent patient outcomes; however, several small factors  when taken together can create a profile that looks similar to providers who get shut down for stealing money or hurting patients. Payers cannot look the other way when provider actions look suspect. Protect your facility by being certain that you follow all the rules and are clear about your business, your coding, your documentation, and your personnel. You never know when you might have to go to the dark side too.

de Zayas Carmean started in the healthcare field at 10 years old, inputting billing data for her parents' medical office. She managed an internal medicine practice and a medical billing service where she coded, billed, and supervised coders and billers for several specialty practices. She also has auditing experience from the auto insurance payer world, where she remains an expert witness in medical coding. She teaches medical administration, finance, and management, and she periodically reviews medical coding textbooks.

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