You know, those conversations you have between another coder and auditor or better yet, those difficult conversations with a physician about the mechanics of the code vs. the intent of the code? That’s what I want to discuss today.
Sometimes this gets lost and it gets the better of us as a coder and/or auditor. We are taught the code is the code based on what is written in the CPT descriptor and that is absolutely right. Please don’t misjudge what I’m saying here in Today’s Take. What I am saying is sometimes we need to pause, and in that pause, we need to read and understand the intent of the code and also listen to what our providers are saying; the intent of the services and what was actually performed. This topic came up recently as a question submitted to us by a NAMAS member. The question surrounded the code 99464, which is attendance at delivery and stabilization of a newborn. The focus was put on the team of coders and auditors as the question came up, the physician was not there for the moment of delivery. However, the physician did provide the stabilization of the newborn. It wasn’t a situation where the provider would have just been there for attendance of delivery and no stabilization was required. The provider actually had to do stabilization when the newborn was delivered. So, let’s put this into an actual scenario. Our provider is running, running, running, trying to get there stat. While the provider is in route, the baby is born. The minute… or maybe the minute after, or two minutes after the baby is born, the provider walks in. (By the way, I don’t know if this is the exact scenario brought up by our NAMAS member. I’m making it up as we go.) So, the provider wasn’t there at the delivery. However, the provider is there and provides everybody stabilization. No pun intended, but do we throw the whole billable service “baby out with the bathwater” and say the service is not billable because the provider was not in attendance at delivery -or- was the intent of the CPT code and the intent of the service met and the stabilization was rendered? We just didn’t physically have that physician in the room at the time of the delivery, but everything else was there. He or she was there right at the time of delivery – just not at that moment, but stabilization of the delivery occurred after the delivery. Now we could put caveats there. “Well, what if they got there then stabilization didn’t happen” Well, stabilization didn’t occur so then… no. There are caveats you can put on my example, of course, but what you do in these situations is what Today’s Take is about. Our job as coders and auditors is to look at charts, analyze – and if you’re a coder…code, and if you’re an auditor, look at what is documented and coded, and analyze for accuracy. When we hit a gray area, it is our job to say “time out, we have a gray area here and this may be above our pay grade”. It’s our job to do our research and our analysis. We do our analysis of this code to go back and say, “OK, these are the RVUs associated with this code. Here’s the CPT code description. Here’s the latest description of the code. Here’s some research I’ve done on this code, and here are the published articles that I can find from reputable sources” (Not opinions that consultants, even like me, have written about this service. These are published guidance articles of what the expectations of this code are.)
Then, we go to the physician or the provider of the service and we ask the provider for details of this service and to explain exactly what happened because the documentation indicates they were not present at the time of delivery. So, we get details from the provider’s perspective of the service. We then write up everything and present our findings to compliance. It is not our job to make the decision on whether we’re going to take the compliance risk or whether that’s too much risk for us. So, we go to compliance and we let them make those tough decisions because that’s their job. Let their legal minds put those decisions to rest or move forward.
So again, what is the coding mechanics and what is the coding intent? Sometimes I’m just asking you as a coder and auditor. I’m not asking you to turn a blind eye, I’m asking you to think outside the box. What is the intent? What is the mechanics? What makes sense?
I’m going to do another post related to this topic a little bit later on addendums. I had a very interesting conversation not too long ago about the use of addendums. What is the intent? What is the mechanics? So, stay tuned for that.