Who does the Coding for Physician Services?

The stakes are high. Coding drives revenue.  Coding compliantly is demanded of all practices. Physician compensation is often determined by the RVUs associated with the CPT code that is submitted on the claim form. Health systems and hospitals want to ensure that services submitted under the group NPI are accurate and represent what was done and documented?

The real question is who is responsible for coding physician services? The medical provider or the coder? Who gets the last word when there are disagreements between what the physician coded and what the coder coded isn’t easily defined. There is no free lunch here. There will be issues to identify and problems to solve no matter which professional does the coding.

The answer is straightforward:

The rendering provider is the only individual authorized to select and responsible for selecting a CPT code. CPT codes are physician procedure codes, found in Current Procedural Terminology, published by the American Medical Association. The codes dictate the work done for payment purposes. Legally, when a physician, physician assistant (PA), or nurse practitioner (NP) enroll in a Medicare, Medicaid, or commercial insurance, the practitioner signs an agreement attesting that accurate claims will be submitted. The practitioner is responsible for claims submitted under his/her NPI.

As per CMS E/M guide, “When billing for a patient’s visit, select codes that best represent the services furnished during the visit. A billing specialist or alternate source may review the provider’s documented services before submitting the claim to a payer. These reviewers may help select codes that best reflect the provider’s furnished services. However, the provider must ensure that the submitted claim accurately reflects the services provided. The provider must ensure that medical record documentation supports the level of service reported to a payer. You should not use the volume of documentation to determine which specific level of service to bill.”

The back of the CMS 1500 form specifically states that by signing the form the provider is attesting to the accuracy of the codes submitted. The fact that the claim is submitted electronically does not change that attestation. That is, whether the medical practitioner or a coder selects the code, the practitioner is responsible for the codes submitted on a claim form.

In many private practices, the physician alone is responsible for selecting codes, based on the documentation, and this is done in the EMR, at the time the note is complete. In some academic practices or health care systems, and in groups that are employed by hospitals, all services are coded by a coder. There is one scenario in which it would be appropriate for someone to change a CPT code selected by a rendering physician, advanced practice nurse, or physician assistant. That scenario is when a certified professional coder has been engaged to audit documentation and the coder finds that the clinician’s documentation doesn’t justify the CPT code selected. Even then, the coder should tell the clinician what changes are being made and why.

Avoiding confusion between Provider and Coder

An internal compliance review will often identify either service that needs review or providers who need education or who need to have all of their coding done for them.

If coders are reviewing notes and changing the codes after the provider has coded them, there should be a mechanism to let the administration and the medical director know how frequently this is happening, and in what direction the codes are being changed.

Most clinicians don’t want additional emails every time a code is changed by one level. Develop a threshold for alerting administration, the medical director, and the provider about when to have a discussion and review. If 15% or 25% of codes are being changed by the coder, that requires a review and discussion. If the disagreements can’t be resolved internally, send a selection of notes to an outside firm for review.

Everyone in the practice shares the same goals of providing medical care for patients and collecting enough revenue to keep the doors of the practice open. In many organizations, coding is centralized out of the practice location, reducing the interactions and opportunities for asking a quick question and getting feedback. If that’s the case, the coding department and practice management could set up regular meetings, even lunches to increase the interaction and improve the relationship between providers and coders. Set up regular meetings with providers to give them feedback about their coding and documentation. If there are services that are always bundled, tell the provider. If a procedure is missing something critical, such as the length of the excision, let the provider know.