There are moments in medical coding when the hardest question is not: “What code should I use”, but “What do I do when I am being told to do something that I believe is wrong?”
Medical coding has guidelines for a reason. We have official coding guidelines, payer policies, CMS regulations, NCCI edits, CPT guidance, documentation requirements, and compliance standards because coding cannot simply be based on what is easiest, fastest, or financially preferable., but what happens when you receive a directive that makes you uncomfortable?
Maybe you are told: “Don’t worry about that part of the documentation,” “We’ve always billed it this way,” “That’s our company policy,” “Just follow the process,” “You don’t need to question it,” “The coder isn’t responsible for looking at that,” and “Everyone else is doing it.”
And yet, based on your training, experience, research, and understanding of the applicable guidance, something doesn’t feel right. That uncomfortable feeling does not automatically mean the directive is wrong. None of us knows everything, and sometimes there is additional guidance or information we have not considered, but discomfort should be a reason to stop and research.
Ask yourself: What specifically concerns me about this directive, Is there a written guideline that appears to contradict it, Is there a CMS regulation or payer policy that addresses the issue, Does the documentation support what is being billed, Could following the directive potentially result in inaccurate coding or billing, and If someone asked me to explain why I coded the claim this way during an audit, could I confidently support my decision? That last question can be powerful.
When something does not seem right, don’t rely solely on what you remember from a class, webinar, coworker, or even something you have always done. Go back to the authoritative source. Depending on the issue, that might include CMS regulations and manuals, CPT guidance, NCCI policy, ICD-10-CM Official Guidelines, Medicare Administrative Contractor guidance, payer policies, or other authoritative resources applicable to the service, then document what you found.
There is an important difference between saying “I don’t think we should do this” and saying “I reviewed the applicable guidance, and this is the specific language that is causing me concern.” One is an opinion., the other begins a compliance conversation.
There may be information you do not have. Instead of immediately saying, “This is wrong,” consider asking: “Can you help me understand the guidance supporting this process” or “I found guidance that appears to require something different. Can we review it together?” Give the other person an opportunity to explain the rationale. Perhaps there is updated guidance, Perhaps there is a payer-specific policy, Perhaps you misunderstood the directive, but there is also another possibility; Perhaps your concern is valid.
This is where medical coding becomes about more than knowing codes. It becomes about compliance and integrity. If you have researched the issue, asked for clarification, and still believe the directive conflicts with applicable requirements, consider following your organization’s appropriate escalation process. That may mean discussing the concern with a supervisor, coding leadership, compliance department, privacy/compliance officer, or another appropriate internal resource. Keep the conversation professional and fact-based. The goal should not be to prove someone wrong. The goal should be to determine: What is the compliant way to handle the service?
Most coders never expect to find themselves in this situation. We want to do our jobs. We want to support our organizations. We don’t want to be viewed as difficult because we ask questions, but compliance questions sometimes require uncomfortable conversations. If an auditor later asks, “Why was this billed this way” how comfortable would you be answering, “Because I was told to do it that way.” For me, that is where the issue becomes bigger than simply following a workflow.
Organizations need internal policies and procedures. They help create consistency and establish workflows, but an internal process does not automatically replace an external requirement that applies to the claim. When the two appear to conflict, that deserves investigation. The question should become: What authoritative guidance supports our policy? That is a fair question for a coding professional to ask.
It is easy to talk about ethics and compliance when everything is straightforward. The real challenge comes when doing what you believe is right could make you unpopular. When asking another question would be easier to avoid. When everyone around you seems comfortable with something that makes you uncomfortable. When you wonder whether speaking up could affect your job. Those are difficult situations, and there isn’t always a simple answer, but I believe there is value in remembering why so many of us pursued professional coding and auditing credentials in the first place.
Those letters after our names represent more than passing an examination. They represent a responsibility to continue learning, research our questions, protect the integrity of the coding process, and speak professionally when something does not appear to align with the guidance we are expected to follow. Your gut should not be the final authority, the guidance should be.
So when your gut tells you something is wrong: Research it, Verify it, Find the authoritative source, Ask questions, Document your concerns appropriately, Escalate through the proper channels when necessary, and Remain professional throughout the process.
You may discover that you were missing an important piece of information. Or you may discover that your concern was justified. Either way, you did what a responsible coding professional should do: You asked the question.
Let’s Talk
Have you ever received a coding or billing directive that made you uncomfortable because it seemed to conflict with what you had been taught or what you found in the guidelines?
How did you handle it?
Share your thoughts in the comments. These are conversations our coding and auditing community needs to have.
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