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Thread Topic: Coding Itself
Topic Originator: Steve Verno
Post Date August 26, 2010 @ 9:32 AM
Coding Itself


Steve Verno
August 26, 2010 @ 9:32 AM Reply  |  Email Friend   |  |Print  |  Top

Coding is not like playing Who wants to be a Millionaire or Jeopardy.  Coding is very serious.  Code incorrectly, you deal with trillions of healthcare dollars and it affects not just the provider, it also affects the insurance company, and the patient.  It has a spider effect.  

Coding must be done by a person specifically trained in coding and should be done by someone who earned their coder certification through honest means.  

Forums and Listserves are not the proper place to code.  You cannot post a lengthy message saying Blah Blah Blah, using nice big words, and hope that someone comes along and says 786.50 or 12001.  To be more frank, we dont know that blah, blah, blah or those nice big words were even done or documented.  Ive personally been treated by at least 3 doctors who have coded their claims fraudulently because that is how they always code the visit.  

In some practices, Ive seen the coder fired and the receptionist is unfairly put into the coders position, so now the receptionist has a 2 foot high stack of medical records and they dont know a 250.00 from a 043.  They couldnt code a 99201 from a 99291 if you put a gun to their head.  

We also have disreputable students who commit educational fraud by asking a seasoned coder to do their school work for them.  That student should be kicked out of school or sent to jail.  The teaching institution, if accepting educational fraud, should be closed by the State Board of Education.  I know that is harsh, but the fraud does more harm and increases the cost of medical care through their mistakes which should not be mistakes if they were honest and did their own work.    

The answer is plain and simple.  If you dont have the education to do coding, get it and dont say you dont have the time to go to school.  Just as laws are passed to regulate healthcare, laws will also be passed to regulate the behind the scenes of healthcare with licensing and certification through the State being required for a practice to continue to operate.

Warren
August 26, 2010 @ 8:32 PM Reply  |  Email Friend   |  |Print  |  Top

HELP!! How do we go around  the incidental denial from AETNA? CPT 78451 mod 26 that we billed was denied as incidental to procedure billed on the same DOS. The following are the codes that we submitted..99233...93018 abd 93016 respectively.Thanks

steve verno
August 26, 2010 @ 8:42 PM Reply  |  Email Friend   |  |Print  |  Top

Without looking at the EOB, the medical record, the provider's contract and the patient's summary plan description, it is difficult to respond or appeal.

steve verno
August 26, 2010 @ 8:42 PM Reply  |  Email Friend   |  |Print  |  Top

Without looking at the EOB, the medical record, the provider's contract and the patient's summary plan description, it is difficult to respond or appeal.

Warren
August 26, 2010 @ 8:49 PM Reply  |  Email Friend   |  |Print  |  Top

hmmmm...ok. thanks a lot

steve verno
August 26, 2010 @ 9:44 PM Reply  |  Email Friend   |  |Print  |  Top

Just so you and everyone else understands. (Ive fought Aetna and won)

1.  EOB:  Provides foundation to a possible erroneous denial. You use the EOB to show a benefit that has been denied and next you have to prove the service is a benefit.

2. Medical Record:  Provides foundation to covered benefit that was provided and  denied.

3.  Provider Contract:  If provider agreed to Aetna coding policy, no appeal is necessary and claim wont be paid.

4.  Summary Plan Description:  Provides foundation to show if denied service is a benefit, provides specific details on appeals process and shows if appeal/benefit is under ERISA jurisdiction.  

5.  ERISA:  allows for full disclosure under 29 CFR 2560-503-1 and so you can obtain patients written permission to appeal benefit claim denial.

YOu could use NCCI but Aetna can tell you to give yourself an enema with NCCI. It has no jurisdiction over them, so you have to use another tactic to win.

One cannot do anything half-a$$ed when dealing with the big insurance companies like aetna.  To win, one needs as much ammo as possible.  Send a wimpy appeal and you lose, you lose forever and everyone else loses.



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