Some health care organizations have rules stating that only physicians and other qualified health care professionals who performed a service can enter or change the diagnosis or Current Procedural Terminology (CPT®) codes for an encounter, procedure or service that a patient receives.
But such organizational practices are based on the incorrect assumption that billing and coding professionals are not allowed to make these entries and changes.
An AMA review of current guidelines shows that physicians and other qualified health care professionals must ensure that the correct diagnosis and CPT codes are used. However, other authorized, appropriate individuals are allowed to physically enter or change the code. If the person entering or changing the code is not the physician, they should consult with the physician to ensure that any update that is made properly reflects the service provided.
The AMA is spreading the message as part of a series of “Debunking Regulatory Myths” articles that provide clarification to physicians and their care teams in an effort to reduce the administrative burdens that divert doctors’ attention from the delivery of patient care.
The AMA STEPS Forward® “Reducing Regulatory Burden Playbook” goes a step further, giving physicians specific strategies to avoid overinterpreting the rules and help advocate for changes in their health systems.
As the leader in physician well-being, the AMA is reducing physician burnout by removing administrative burdens and providing real-world solutions to help doctors rediscover the Joy in Medicine™.
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What the regulations show
The AMA found no federal regulation or CPT guidance that mandates that only physicians or other billing health care professionals can enter or change codes either before the office submits the claim or after a payer denies a claim and a code or codes need to be corrected.
Here’s what the regulations and guidance show:
- Federal regulations and CPT guidance does not prohibit certified professional coders from reviewing diagnosis and procedure codes, respectively, for compliance with reporting guidelines and regulations.
- Centers for Medicare & Medicaid Services (CMS) evaluation-and-management (E/M) guidelines say that a billing specialist may review documentation before submitting or resubmitting a claim.
- Meanwhile, the International Classification of Diseases, 10th Revision, Clinical Modification (ICD-10-CM) guidelines say that “a joint effort between the healthcare provider and the coder is essential to achieve complete and accurate documentation, code assignment and reporting of diagnoses.”
- CPT guidance requires that the performing health professional maintain responsibility for correct coding, making the collaborative relationship between coders and physicians important so that the appropriate diagnosis and procedure codes are submitted.
Earn CME credit
Learn more with the “AMA Debunking Medical Practice Regulatory Myths Learning Series,” which is available on AMA Ed Hub™. For each topic completed, a physician can receive CME for a maximum of 0.25 AMA PRA Category 1 Credit™.
Physicians who would like clarification about a potentially misinterpreted rule or regulation that has burdened them or their care team are encouraged to email the AMA’s experts, who will research the matter. If the concern turns out to be a bona fide regulation that unnecessarily diverts physicians’ time and focus away from their patients, the AMA can advocate for regulatory change.
