Author: Bob Burleigh
Healthcare Business Management Associates
Navigating Gray Areas in Documentation and Coding
The Issue
Not every coding decision is clear-cut. Physician documentation may by incomplete, ambiguous, or inconsistent with the level of service apparently provided. In those situations, billing employees face a recurring temptation: to fill the gap — to select a code that “seems right” based on context, specialty norms, or historical patterns, without adequate documentation support. This poses ethical and, potentially, legal risks for the employee, the company, and the client(s).
Why It Arises
Experienced billers and coders develop long-term experience, as well as strong instincts about what a particular provider typically documents and what they likely did. Those instincts can be valuable — but they can also lead to assumptions that substitute for documentation. “When [the provider] does X, it always includes Y. but sometime s/he forgets to mention it in the documentation.” The difference between asking a provider to clarify their note (appropriate) and modifying a code to match what the biller assumes was intended (not appropriate) is a line that erodes gradually under time pressure. Conversely, modifying a record to match the code can be equally problematic, and can also violate state laws governing amending medical records.
The Ethical Responsibility
It is often said that coding is both an art (creative) and a science (facts), although science should be the sole descriptor. Compounding this is how insurers (mis)treat the coding process in ways that clearly demonstrate an adverse – and unethical – financial interest in their opinions and policies about coding. Further, there are myriad consultants and purported “experts” who claim to have the most precise and accurate knowledge of “proper” coding. However, the only ethical basis for securing an objective answer to a coding question is to reference so-called “authoritative sources.” Those sources are the American Medical Association, which owns and publishes the CPT codes, as well as the AMA’s companion publications, the publishers of ICD-10 (Coding Clinic – American Hospital Association) and DSM codes, CMS – for HCPCS codes, and very few others. For Medicare and CMS-related claims, the Medicare Correct Coding Initiative is authoritative for HCPCS and Medicare coverage of CPT codes. MedLearn Matters is another officially recognized source.
Medical professional associations and societies routinely publish coding analysis and opinions, but their inherent bias prevents them from being authoritative sources. Billing companies have an ethical, as well as a compliance, obligation to assure that their coding – and acceptance of clients’ coding – conforms to authoritative sources, only.
The standard is clear: coding must be supported by documentation in the medical record. When documentation is insufficient, the correct response is to query the provider — not to assume, infer, or select the most favorable code available. Queries should be neutral and open-ended, presenting options based on clinical indicators without leading the provider toward a specific answer. A well-designed query process is not a barrier to productivity; it is a foundation of ethical compliance.