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Understanding your role in corporate compliance for billing and coding staff

Staff Development Weekly: Insight on Evidence-Based Practice in Education, May 18, 2004

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Question: Emma was recently certified as an Accredited Record Technician and is new at ABC Medical Center. Reviewing physician documentation, she questions whether the diagnosis of sepsis is correct because the documentation states urosepsis. The claim has not been submitted. She brings it to the attention of the attending physician, Dr. N., only to be rebuffed.
"I'm sure that whichever I wrote was accurate," says Dr. N. "It would be helpful if you check these things with one of the other clerks first."
Doubting herself, Emma decides that the record is complete enough and files it for submission as sepsis.

What would you do?

Answer: While her first instinct was correct, Emma dropped the ball on this one. Sepsis and urosepsis are distinct diagnosis-related groups (DRGs) and pay differently. No one expects you to challenge a physician under these circumstances, but the claim cannot be filed if its diagnosis is unclear. Emma should hold the record and bring it to the attention of her supervisor. She should apply problem-solving skills to offer a solution when presenting the record to her supervisor. The supervisor could then bring it back to the attending physician or, perhaps, flag it for concurrent audit, creating an educational opportunity.

Editor's note: The above case is from the online course "Understanding your role in corporate compliance for billing and coding staff." For more information on this and other Compliance courses, go to www.hcprofessor.com and click on Compliance.

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