Can you help with coding disputes with payers when they don’t follow Coding Clinic advice or the Official Guidelines for Coding and Reporting?
Traditionally Coding Clinic does not address coding for reimbursement. Coding Clinic’s goal is to provide advice according to the most accurate and correct coding consistent with ICD-10-CM and ICD-10-PCS principles. The official guidelines are part of the HIPAA code set standards. There are a variety of payment policies that may impact coding. Some payment policies may contradict each other or may be inconsistent with coding rules/conventions. Therefore, it is not possible to write coding guidelines that are consistent with all existing payer guidelines.
The following advice is provided to help providers resolve coding disputes with payers:
- First, determine whether it is really a coding dispute and not a coverage or payment issue. Therefore, always contact the payer for clarification if the reason for the denial is unclear.
- If a payer really does have a policy that clearly conflicts with official coding rules or guidelines, every effort should be made to resolve the issue with the payer. Provide applicable coding rule/guideline to payer.
- If the payer refuses to change its policy, obtain the payer requirements in writing. If the payer refuses to provide their policy in writing, document all discussions with the payer, including dates and the names of individuals involved in the discussion. Confirm the existence of the policy with the payer’s supervisory personnel.
- Keep a permanent file of the documentation obtained regarding payer coding policies. It may be come in handy in the event of an audit.