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When Coding—Remember You are NOT the Doctor—And Don't Blindly Trust the Software

Steve Verno, a seasoned and experienced certified medical biller has shared the following with us today:

"I've seen the following scenario at least 5 times this morning."

Scenario:

"Someone sends me a message along the lines:

My doctor performed XXXXX and he diagnosed the patient with 000.00.  The insurance company, ABC, denied the claim saying 000.00 cannot be used with XXXXX.  I use XYZ Software to code and it says if we want to use XXXXX, it needs 999.99 as a diagnosis.   The doctor will not change the diagnosis to 999.99.  Is there another diagnosis I can use to get XXXXX paid or is there a procedure I can use with 000.00?

When we code, we must always refer to the doctors documentation of the service (procedure) rendered and the diagnosis documented by the doctor.  We cannot and should never code based on the lack of observing documentation.  While software is nice, the software may have been created by an insurance company and it may be biased towards that insurance company's internal coding policies.  There have been lawsuits regarding an insurance company's software where the courts have found that the software was biased for the insurance company.  While software may be a nice adjunct, it can never replace good old fashion brain matter where we open the coding book and use our coding training to look up a correct code. 

In medical coding, a diagnosis is always selected by the doctor.  We are not doctors and we cannot make up a diagnosis just to get a claim paid. We, as coders, take the doctors diagnosis and convert that diagnosis to a code we submit on a claim.  Medical coders never diagnose. There are rules to follow.

If those rules result in a claim denial, then we may have no resolution, but we can never take shortcuts or look for loopholes or make up anything to get a claim paid.  We can never code without reviewing the medical record documentation.  Our commitment is to prevent and never accept or allow fraud or abuse." (Steve Verno, Certified Medical Biller).

To read more real-life anecdotes and medical billing tips from Steve and others visit our Medical Billing Community forum.
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