Corporate Compliance

Physician asks coder to change codes

Compliance Monitor, December 2, 2005

Q: I am the ancillary coder for a small rural hospital. Several doctors have recently written orders that have caused me coding dilemmas.

In one case, a patient came in complaining of a headache and dizziness. While the patient was there, the doctor wrote an order for screening lipids, glucose, complete blood count, and a comprehensive metabolic panel. This order was written for the specific purpose of having lab results for the patient's upcoming preventative annual exam, which had been scheduled for two weeks later. I coded the ancillary account according to the order with headache and dizziness as the primary and secondary codes along with the screening labs. Meanwhile the patient saw the doctor two weeks later for the annual exam and reviewed the lab results. A month later the patient received an explanation of benefits (EOB) from his insurer indicating that the screening labs are not payable. The patient called the doctor, and the doctor requested that we change the codes to reflect that they were part of an annual exam. I denied code changes because the primary reason for the visit was a problem and no annual physical exam took place. The doctor is now requesting that I provide him with documentation as to why I must code the way I did.

In another case, the doctor received a phone call from a patient two weeks prior to the patient's annual exam. The patient requested that the doctor order any labs he wants prior to the appointment. The doctor faxed an order to the hospital, the patient had the labs, and the labs were reviewed at the annual exam. The doctor contacted us requesting a code change when the patient received their EOB denying payment of the screening labs. I requested office notes for the date of service on which the labs were ordered. The notes reflect that the doctor responded to the patient phone call by ordering the labs. However, the patient was never seen by the doctor on that date. No physical exam took place.

I would appreciate any information that anyone can provide to resolve these issues.

A: When performing ancillary services it is always advisable to inform the patient of potential non-covered services in the manner of issuing an advance beneficiary notice (ABN). In this coding scenario, the coder has acted responsibly and per the federal guidelines, coded what was documented on the order. Instructions on Program Memorandum AB-01-144 under section B Instruction to Determine the Reason for the Test relate that an order may include a written document signed by the treating physician/practitioner, which is hand-delivered, mailed, or faxed to the testing facility. These instructions also refer the reader to the Federal Register, 42 CFR 410.32 that all diagnostic tests "must be ordered by the physician who is treating the beneficiary." This is further clarified in the Medicare Claims Processing Manual under 10.1.2 Instructions to Determine the Reason for the Test (Rev. 1, 10-01-03) "The Balanced Budget Act (BBA) |4317 (b) requires the referring physicians to provide diagnostic information to the testing entity at the time the test is ordered." The documentation in the medical record should always support the data coded for billing submission.

Thank you to Cheryl Bowling, RHIT, CCS, CHC, compliance director for Kforce HealthCare Staffing in Tampa, Fla. for providing this answer.

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