r/MedicalCoding

I recently was dinged in an audited for coding F10.90, the provider documented it as alcohol use, unspecified, uncomplicated. It was explained the code cannot be used without severity or a link to a mental health disorder. The provider is even managing medication for this diagnosis. It feels odd to leave it off the encounter and that there isn't anything else to replace it with. Is this just a weird ICD instance where the code ends up deleted and move on?

I've been stumped by a recent new client's claim through Medicare who's seeing our practice for individual psychotherapy sessions and was hoping someone more experienced could clock what's going on with this client.

(I've been working in the field for a little over a year and a half for a small practice, but whatever it is I've never encountered before)

We have a Medicare card on file for the client (with Medicare entered as the primary policy) and it shows as active in the Wellpoint Federal portal. However, the initial claim was rejected under code 834, saying "Claim/service not covered by this payer/contractor. You must send the claim/service to the correct payer/contractor."

Taking a look at what the client entered as supplemental insurance, it's a Molina Medicare Complete Care Plus plan, and the card says it's a HMO D-SNP plan that contracts with Medicare and our state's Medicaid.

We're in-network with Medicare but not Medicaid, and I was under the impression that whenever someone had both, Medicare would be primary and Medicaid would be secondary. That doesn't seem to square with the rejection message or the presumed secondary policy being a HMO plan, which I thought could only be the case with primary policies.

I'd greatly appreciate any help in understanding what's going on here, and if we're out of network despite the Medicare card, I'd like to know where I should have been able to catch this.

Thanks!

I do billing on the eye care side, and I wanted to share the scenario that gives newer billers here the most trouble, because it is the rare mistake that never announces itself with a denial. I am curious whether other specialties have their own version of it.

The setup: a patient comes in and hands over a vision plan card, VSP or EyeMed. Front desk sees the vision card and bills the whole encounter to the vision plan as a routine exam. Done. Except the patient's actual reason for the visit was dry eye, or flashes and floaters, or diabetic eye monitoring. That is a medical presentation. It should have gone to the patient's medical carrier with the medical diagnosis, not to the vision plan.

Here is why it is dangerous. When you misroute a medical visit to a vision plan, the vision plan just pays its flat routine allowance. Nothing denies. There is no CARC, no rejection, nothing lands in the denial queue for anyone to work. The practice got paid, so on paper it looks clean. But the medical carrier would have reimbursed that medical exam, the appropriate 920xx or E/M, at a higher rate, and that difference is simply gone. It is an invisible underpayment, which is arguably worse than a denial, because a denial at least shows up somewhere and someone works it. This one nobody ever sees.

The decision rule I go by: the chief complaint drives the plan, not the card the patient hands you. A medical complaint or medical diagnosis in the chart means the exam is medical and bills to the medical plan with the medical dx primary. No complaint, purely a refractive check for glasses, means routine and bills to the vision plan with the refractive dx. And the refraction itself, 92015, is statutorily non covered by Medicare and most commercial medical plans, so it is patient responsibility or goes to the vision plan even on a medical day. You can absolutely split one visit, the medical exam to the medical carrier and the refraction to the vision plan, when the documentation supports it.

The reason it stays a problem is that the routing call happens at the front desk at check in, before a coder ever touches the chart. By the time it reaches billing, the plan is often already locked and the whole encounter has been built around it, so the coder is fixing it downstream instead of it being right at the source.

A couple of real questions for the group. For anyone in eye care, where does the medical vs vision call actually get made in your workflow, the front desk or the biller? And for everyone else, does your specialty have a similar silent underpayment, some scenario where the wrong payer pays cleanly and the loss never surfaces as a denial? I have a feeling every specialty has one, and they rarely get talked about precisely because nothing ever errors out.

Hi - I'm starting a new job as an acute care inpatient coder. In my previous job we used Altera Digital Health EHR. In my new job the EHR is EPIC. Any tips on learning EPIC? How steep do you think the learning curve is?

Hi! I'm currently pursuing medical coding & billing, and I'm so excited!!! I'm trying to visualize what life will be like for my 5 year plan. So I had some questions for life outside of your day to day coding work?

Do you enjoy your job?

Do you get to vacation?

Are you able to support yourself well/do you worry about bills?

Does it ever get mundane, or does it depend where you work?

Do you get to have fun with your looks, like fun colored hair, tattoos or piercings?

How is asking for time off, or if you're a parent, what happens if there is a family emergency/sick child?

Thank you for any help with even one of these! ☺️

I just found I pass my CPC exam with 72%, I am so happy, now I just need help as to what is next after this because tbh I have never thought of my next move if I pass

Thank you

Hi folks,

I’m not a coder, I’m in follow up/denials management. So I hope this post is okay.

My org is restructuring from payer based to specialty based. I’m used to doing all specialties which was nice because I had the somewhat autonomy to choose what to work each day.

Now I have the opportunity to choose a specialty but I’m kind of stuck.

I don’t think I would want to do solely Emergency med or internal medicine, I feel like it would be very repetitive. And to do it nonstop all day… yeesh. HOWEVER, it would probably be minimal phone time with insurance reps. Usually it’s appealing e/m leveling denials.

I do like when High dollar claims(surgery/ortho/oncology/etc) finally pay, but at times I can get frustrated along the way. Especially phone calls with offshore reps. It can be a lot of work, but it is rewarding…

If you could choose, what would you pick and why? Absolutely no patient interaction, thankfully. In case that matters.

I hear coding directors say they’re struggling to find coders, and coders say they can’t find a job!

After some investigation into what’s going on in the hospital where I work I can confidently say our job descriptions are awful and nobody is taking the initiative to change them.

Our job descriptions make no mention of remote. We have been remote since the pandemic and we actually have no physical space in the hospital.

We still mention ICD 9 and list more required experience than we will accept.

We don’t post outside of our hospital job site.

As a matter of fact I only applied years ago as a new coder because I emailed the coding director looking for advice and she offered me an interview.

I wouldn’t take hospital job descriptions as absolutes. I also wouldn’t trust HR with my resume. Honestly, I would network and reach out to coding directors. If this offends them, they’re not who you want to work for anyway.
Check hospital job sites directly. Think outside the box and don’t forget coders are everywhere. Check your college job sites, I know several college coders.
Just my morning thoughts on coding this morning lol

I’ve been a CPC-A since 2024 finally secured my first coding specialist role! 100% remote, flexible M-F schedule! I’m thrilled. It’s been 9 months of unemployment and over 800 applications. I did it! Bring it on!

So I accepted a job offer for an inpatient role, although I was trained/certified in outpatient.

If i gave myself a crash course in the next 2 weeks, what would you say is the most important concepts to learn when just starting out?

I'm just wondering what is more realistic and pairs better with medical coding? Would it be medical billing or medical assiting? Is there anyone that has been able to do both at the same time? I'm just trying to build a stable path for the next five years..

I am in my first year of coding. I currently risk adjust but am leaning toward getting COC certified. When I go and explore different available positions, an associates degree is always in the "required" section. Is not having a degree something that can hold you back? Im actively trying to map out how I want to further my path within this career field.

SO im in my course and the codify section is optional, but of course i did it becaise well, im an Ex IT guy and i know software is going to be the way to go, the books are easy, yet bulky, and time consuming, but i dont like codify, i think its all over the place, So im wondering are you using codify or does your employer/ facility/office, use a different system?

Been doing eye care billing for a while and the error that costs practices the most is not the one that gets rejected. It is the one that pays perfectly.

Here is the pattern. Patient comes in with a real medical complaint, dry eye, flashes, a diabetic follow-up, whatever. Front desk sees they have VSP or EyeMed, runs it as a routine vision visit, and it pays. S0620, refraction, done. Clean claim, money in the door, nobody thinks about it again.

Except that visit had a medical diagnosis attached to it and could have gone to the medical carrier as a 92014 or an E/M with the medical dx. The vision plan paid maybe 60 to 90 dollars. The medical claim would have paid meaningfully more, and it would have preserved the patient's routine benefit for when they actually come back for glasses.

The reason it is so easy to miss is that there is no denial to work. Denials get worked because they show up on a report. This never shows up anywhere. It just quietly pays at the lower number, and the only way to catch it is to look at the routing decision before the claim goes out, not after.

The way I started catching it: flag any visit where the chief complaint or the dx is medical but the claim got built to the vision plan. Even a rough monthly audit of that overlap surfaces money nobody knew was leaking.

Curious if others here have a way of catching this on the front end. Do you route at check-in based on chief complaint, or do you let the biller sort it after the encounter? I have seen both and I am not sure which actually loses less.

I paid to renew in March and I got an email saying that it’s been 95 days that I have to re certify. I emailed them the receipt that I already paid for the year of $229. I did this over the phone just like the year prior. They said the Ceus were never applied and now my cert is gone although I paid. Please help! Any advice? I am in tears

Okay I have a question. I code for a remote coding company that contracts with several different health systems, and recently management at my company started really micromanaging us. They used to really only care if you met the amount of charts the client wants per day, but now they want us coding every single second and they want all of those seconds accounted for. And they’ve recently threatened us stating that clients are actively tracking our coding time within their health information systems (specifically for me it would be Epic and 3M HDM) and if they do not match perfectly with our time sheets we submit, they consider it “fraudulent billing” my question is: can the clients truly run reports on us showing accurately how long we were in the systems, and also, if the time doesn’t match what we report on our company timesheets, is that truly fraud if we are completing the number of charts we say we are completing?

Thanks in advance. All of this micromanaging is really getting out of hand and is distracting me from my actual job.

Hello! I've just about completed my first year of coding. I was very lucky I got a job the same month I got certified. I've been RA coding and am thinking about getting my CRC. I read some previous post about how being on this path can get sticky with staying up to date with CPT coding. I don't want to get locked onto this path, but I also want to build my resume. I have no previous medical experience outside of school and I am also a contractor, so no job security when furlough season kicks in. I would love some advice or shared experiences that may help me navigate. I am also thinking about getting certified in billing if all else fails. Thanks! 😊

So I'm getting near the end of my Associates to qualify for the RHIT exam, and havw to do a second 90 hour practicum to meet the 180 hour requirement. Last one I had I got to work in an RCM department, it was great. Wish they would have hired me, aha. But they didn't have a spot open.

Anyway, this next one will be remote. I'm transferring schools (and yes the new one is CAHIIM-accredited as well, same state even) and the instructor is well, quiet about details on this. School doesn't start back up for another week, but I like to be prepared and she just refuses to share any details of what the work will look like and to just sit tight until opening week.

It's really frustrating. So I am wondering if any of y'all have experience with remote practicums, if you have any idea of what I can expect as far as job duties. Would it just be coding? Will I be expected to be perfect at it? Because even with studying I still struggle coding some areas, cardio is a nightmare lol.

TIA!

I've been offered a job with Omega healthcare and start next week. I'm starting to get anxious, as I've read some good and not so good things about the job. I'm an experienced coder, but they're offering $7 more than my 4-year coding experience has given me, and they were very quick to offer the job. I'm very curious as to whether or not anyone has any information on it!

I’ve been applying to jobs and have been rejected from some or haven’t heard back at all. And I noticed an email I missed a few days ago from a recruiter from a company I applied for asking to do an assessment. And since this is my first coding jobs ever, I’m not sure if this is normal for the assessments to be on Google forms.

It’s a total of 20 questions all but one is multiple choice. I also am not sure of the sequence of these things. Like would the assessment come first or after the initial interview? Sorry for the stupid questions, this is my first time in this field. Thanks!