Q: I’ve recently received my CPC certification – congratulations – and now I’m currently working in the coding department and I’m struggling. There have been a couple of instances when I’ve been told that I am billing for services when there isn’t proper documentation. My employer thinks that since we’re certified we should now know everything. Can you give me any advice? Christopher.

A: Well, Christopher, yes, since you’re certified, you will be looked up to as a person that probably knows more than other people in the office. However, if somebody… you don’t have to be certified to be a coder and you may have some people that have worked there for a long time and are very knowledgeable.

But, going back to documentation, if there isn’t proper documentation then you can’t code it and you can’t bill for it. So, if it’s a supervisor that you can talk to and come back with facts, you need to have examples and scenarios then plead your case with them, let them know. Don’t say, “Oh, you could get audited” or “The Feds are going to come in,” or Tammy was saying, “I hope you like the color orange” the other day in the auditing class. But, I would just try to plead my case and give good examples of what the proper documentation would look like. However, you’re not talking to the physician, you’re talking to your supervisor; you got to be very careful when you’re talking to the physician.

Medical Biller and Coder | Advice for a New Coder – Video

And if without the documentation, you can show them, “This is how much we can bill out; this is your reimbursement for that. If we have this documentation, which is what I think that you do or you did, we want you to get paid for the services that you’re providing, then we can bill this, and this is a reimbursement that you would receive for that. But we can’t get this without this documentation, and again we want you to be reimbursed for the care that you’re giving.” And see if that helps, because when you talk money and let them see it in black and white, sometimes that helps. So I think I would do that.

Again, if you’re certified you’re called to be at a high standard, so I would just continue my education as much as possible, make sure that you read your AAPC magazines when they come out to you and read articles on forums and Facebook, we’ve got tons of articles. You can Google things if there’s something specific that you don’t know about.

The nice thing about medical biller and coder is that they are proactive and they like to share the information that they learned. They’re usually a very friendly group and they don’t mind sharing knowledge. If you are stumbling with something, there’s somebody out there that can help you.

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About the Author:

Alicia has been working in the medical field for over 20 years. She first learned about medical coding while working in a medical records department at a resort town hospital near where she was raised. Through the years she has held several jobs in the medical field from, CNA, EMT, Pharmacy technician and Medial Records Abstractor and Analyst. Outside of the medical field she has worked as a Real Estate agent, and owned her own on-line retail business. The medical field has always been where she felt the most comfortable. Alicia has taught medical coding, billing and medical law and ethics at a private college. She also did contract work in HCC Risk Adjustment and discovered she really enjoyed ICD work. Because she loves to learn Alicia is working towards her Masters in Health Care Administration with an emphasis on education. Having taken many online classes through the years to complete her degree she feels very comfortable with both face to face and on-line learning. Alicia will tell you that not only does she love medical coding but she has a passion for teaching it. Alicia lives in the middle of Texas with her husband who is a Pastor, five of her six children, three dogs and two cats.

One Comment

  1. Susanne Morse October 30, 2014 at 9:08 pm - Reply

    I am currently a student studying Medical Billing & Coding. I’m excited to learn the in’s & out’s of the position in anticipation of working in the real world.

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