I got an e-mail from one of our successful graduates. I'm going to post bits and pieces of what she had to say, because it will encourage many of you as you learn how to "defend your codes" during your training here.
"Defending Your Codes" at Andrews and later On The Job
It's great to hear from our successful graduates!
As a working coder you will be asked about your codes by managers, auditors and even other employees of the facility like the people that monitor Performance Improvement. If you can defend your code choice by explaining the reasoning and offering a reference you will develop a reputation of being very professional and very good at what you do.
You don't ever want to be the coder that answers the questions with "I coded it that way because that's what we have always done."
Let’s add to the discussion when NOT to defend your codes too strongly.
It isn’t unusual to be in a first coding job and recognize that those around you, maybe even those in charge, are making errors.
There is not much you can do at this point. They are in charge. You do things their way unless it’s unethical or illegal. Your time will come.
Those in charge don’t always have the best of skills. They may have inherited that position because they knew someone or just due to longevity. It doesn’t matter. They are in a position of authority. They may also occasionally be right, so you won’t want to assume that they are always wrong. There are also instances where the physicians in charge have told them that this is the way they want it done. Period.
After you’ve shown them any appropriate guidelines, then drop it. Try to get a cheerful, “teachable” attitude and avoid being seen as someone who thinks they know more than those in charge. Keep a log for yourself to review at some time in the future when you switch jobs, so you can remember any errors that you will have to ‘unlearn’ at that point. Then, make sure that they never have to tell you twice how they want it done. They may begin to see that as a challenge to their authority or threat to their own position, that you (think that you) know more than they do.
The important thing right now is to put in your time, be alert and aware to the way YOU would code something if you were in charge, and …most important of all… don’t threaten those around you who may have not had the excellent training that you had.
The situation may fix itself.
*People come and go. A new supervisor may correct some of these problems.
*The whole group may get additional continuing education and become aware of some of their errors (not likely).
*You will put in your time and find a more excellent position where things are done correctly.
There is never a One-Size-Fits-All solution when we work with people. Right?
Thank you for your comments regarding when not to defend your codes too strongly. I see your wisdom in why you would advise against that and appreciate your explanation.
I would appreciate if you would expand on this a bit. At this point in my studies, I guess I am under the impression that a code is either right or wrong (could have gotten that idea from our tests LOL), and reimbursement can be reduced or denied if we report an incorrect code. If you are being reimbursed too much, you could be found guilty of fraud; and if you are under reimbursed you are losing money, and what good is that?! I would think that physicians/hospitals/clinics would be interested in generating the most income possible, so why would they intentionally want something coded a certain way even if incorrect?
I'm sure I'm showing my ignorance here, but I'm trying to understand things from their perspective or determine if I have somehow formed incorrect ideas.
Debby may want to expand on this. From my own experience, I know of a local doctor who did go to prison for up-coding, coding for procedures that weren't done. Most of our graduates work for hospitals where the doctors aren't involved in coding decisions. If you were in a doctor's office (most doctors can't afford credentialed coders, so that wouldn't happen often) where you were instructed to code fraudulently, you would leave.
The situation would be more likely be a coder working for an outpatient clinic where the person in charge of coding isn't aware that they are under-coding, resulting in problems with reimbursement. There might be rejection letters followed by the Billing people having to make phone calls to resolve those issues and get payment.
Delays in payment are a big problem for medical clinics. If they don't get paid, they can't pay their own bills. This is also where you might hear, "We've always done it this way."
The doctor may have gone to a seminar on a cruise with lots of other doctors at some point where they were taught to code a certain way, even possibly using a Superbill where things are circled with little thought or effort. At that time that may have been the correct code but, as you know, things change. Doctors don't always update the coding skills related to their specialty or sub-specialty, so they may not be aware that anything changed. They will probably eventually be paid, but maybe not as much as if they had coded properly, and maybe with a long delay and lots of time wasted by the Billing Dept talking with insurance companies, etc.
In these cases, the coder who knows that there is a (small) error that would make a (big) difference in reimbursement, may not be in a position to get that changed. In my experience, it typically takes about 3 years for someone in a medical office to have built the credibility where they will be listened to about much of anything.
If you have the proper credentials, you are more likely to be listened to, but when you're working with people, one never knows. It doesn't always work that way.
Hopefully Debby will drop by to add more to this discussion.
Correct coding is very important for a number of reasons. Reimbursement depends how the charts are coded and billed. There is also an audit risk if your facility or office has a history of coding errors.
You do need to remember to separate the coding from the office process. Coding is done based on the documentation, guidelines and advice from Coding Clinic or CPT Assist. The office process is determined by the owners or managers of the office or facility and they will let you know how they want something done. A physician's office is usually a more controlled environment than a facility.
Most students will go to work for a facility doing either inpatient or outpatient coding. There will usually be policies written for what procedures are to be coded and general coding instructions about following the guidelines and relevant AHIMA Practice Briefs.
The coder is responsible for the codes assigned on any chart they code and you have to be able to defend your codes with documentation such as the guidelines and/or the coding clinic. At times the documentation can be subjective and two coders will come up with different codes based on the same documentation. If you are asked to change your codes in this type of situation go ahead and do so unless there is a guideline or coding clinic conflict.
There will also be times that an insurance company will audit your chart and refuse to allow something to be coded. This is very common and an appeal is usually written but if it's denied then the code will be deleted. This doesn't mean that you coded something incorrectly it just means that the insurance company does not think there is enough documentation to assign the code.
When there is a CMS, RAC or corporate audit and you are asked to change or delete a code the first thing you should do is review the documentation, guidelines and coding clinics. It's also a good idea to talk the findings over with your supervisor.
I have found that a majority of coding managers will back you up provided you are correct. Once in a while you will come across a manager that is a bit scared of auditors and they will want you to change the code even if you are right. Remember that it is your name on the chart. At this point you have two choices the first being to delete the code and the second to tell the person requesting the deletion that you won't delete the code but if they want to and have their name put on the chart that would be fine.
Remain professional at all times in order to let your credentials and coding track record speak for itself. When you accept your first position there is no need to let your coworkers know that this is your first job unless the manager wants you to.
Every facility is different but as long as have your credentials and code in a professional manner you will do great.