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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Should Medical Coders Rely on Medical Coding Software?

Steve Verno, a seasoned and experienced certified medical biller and billing instructor has shared the following:

"I've seen billing companies undergo audits, sanctions and fines because their medical coders became too reliant on medical coding software.  They couldn't code without it."

Here is an interesting story taken right-out-of-real-life illustrating what can happen if medical coders aren't properly trained bottom up to know how to hand-code using their manuals and books:

"We were hiring some coders at one time. 10 of them came in.  All nurses with certification. They were put in our training room. All they had were the CPT and ICD-9 manual and paper charts.  Some of the coders asked where the computers and software were.  They were told there would be no software.  They were all told they had to code using what was provided to them.  Only one passed the coding test. She lasted one day on the job.  She went from coder to coder asking them what code they would choose.  She even came to me and I didnt have coding training at the time.  The owners found her using the internet to get her codes.  At her outbriefing she said she used coding software at her last job.   The ones who demanded the software hired a lawyer saying the test was unfair.  They lost their lawsuit.  The company eventually hired some coding students who just graduated from school.  Brain power makes the best coders.  Software never guarantees 100% accuracy with coding." (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.

Buying Medical Billing Software

While we cannot make any recommendations on which medical billing and office management software to to use we can give you some examples of those we have used, and indicate which ones we liked. I liked Lytec, Web MD's Medical Manager, and ZirMed.

We don't know anything about the rest of medical billing software that's out there, but we know what to look for! (Much!) more tips on selecting Medical Billing Software that works:

* It has to produce AR reports on demand
* Individual insurance reports
* Individual account report
* Monthly payment report
* Monthly overpayment report
* Monthly adjustment report
* Monthly time payment report
* Debt collection report

It's important to ask about clearinghouses!

• When selecting a clearinghouse, make sure you find out how many insurance companies they send claims to
• Are you required to use their software, or one of your choice?
• How much will it cost you per claim to send to the clearinghouse?
• What reports will you get?
• Will you get a confirmation of receipt of claims not only by the clearinghouse, but also by the carrier?
• Will you get a claims adjudication report?
• If the claims were sent to the clearinghouse and the insurance company says the claim is not on file (NOF), what will the clearinghouse do to rectify this?
• Do they resend for free, or do you get a refund?
• Make sure your contract has a no-penalty termination clause and you can terminate for any reason without penalties.