Ask Caryl: Coding in Sync with Your Providers

Q: A provider has asked me to code a procedure differently than is dictated in the operative note. What should I do?

Caryl Serbin: The administrator and the coder should speak with the provider and present what procedure code(s) the coder has selected based on the dictated documentation. Ask the provider to explain why they feel a different procedure code(s) should be billed and how the documentation supports that decision. The coder may have misunderstood the surgical technique or language in the procedure note. If so, ask for further clarification so the coder will better understand the surgeon’s documentation and techniques in the future.

However, if this is not the situation, and the provider performed techniques not supported in the operative report, ask them to dictate an addendum to the procedure report to fully document the services provided. Explain that the procedures code(s) requested cannot be billed because the documentation does not support them.

Remind the provider that, in the event of an Office of Inspector General (OIG) audit, medical records are reviewed for accuracy against services billed. If the documentation does not support the billing submitted, any payment received will be taken back, along with any fines or penalties that may be assessed. The auditor’s guidelines are “if it isn’t documented or legible, then it was not done.”

If there is still a problem with provider compliance, contact your compliance officer so they can investigate the situation and determine appropriate action.

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