This resource is part of the AMA's Debunking Regulatory Myths series, supporting AMA's practice transformation efforts to provide physicians and their care teams with resources to reduce guesswork and administrative burdens.
Debunking the myth
While physicians and other qualified health care professionals are responsible for ensuring the use of the correct diagnosis and Current Procedural Terminology (CPT®) codes, other appropriate individuals may physically enter or change the code when authorized. This should be done in consultation with the physician to ensure that any update reflects the service provided.
There is no federal regulation or CPT guidance mandating that only physicians or other billing health care professionals may enter or change diagnosis and procedure codes when the need arises either before a claim is submitted or after one has been denied and requires correction. Likewise, there is no federal regulation or CPT guidance prohibiting certified professional coders from reviewing diagnosis and procedure codes, respectively, for compliance with reporting guidelines and regulations.
The CMS E/M guidelines state that a billing specialist may review documentation before a claim is submitted or resubmitted.1 Additionally, the ICD-10-CM guidelines state, “a joint effort between the healthcare provider and the coder is essential to achieve complete and accurate documentation, code assignment, and reporting of diagnoses.”2 CPT guidance requires that the performing health care professional maintain responsibility for correct coding, so the collaborative relationship between physicians and coders is important to ensure that the appropriate diagnosis and procedure codes are used.
Background
In many health care settings, a procedure or service is reviewed by a certified professional coder or other billing specialist before being submitted as a claim to the payer.1,3 In some instances, CPT codes and/or the associated diagnosis codes need to be adjusted to match the service provided or corrected if the wrong code was selected by mistake. Some organizations require that these changes be made only by the physician or other qualified health care professional who performed the service, incorrectly assuming that billing and coding professionals are not permitted to make such changes.
AMA policy
Resources
- CMS August 2023 Evaluation and Management Services Guide MLN Booklet (PDF) (Accessed 2024)
- “8 Medical Coding Mistakes That Could Cost You” AMA Article (Accessed 2024)
- Simplified Outpatient Documentation and Coding AMA STEPS Forward® Module (Accessed 2024)
- Download this myth: Entering a diagnosis and procedure code (PDF)
References
- CMS. Evaluation and Management Services Guide. In: Medicare Learning Network (MLN) Booklet.; 2023:1-21. Accessed April 11, 2024. https://www.cms.gov/outreach-and-education/medicare-learning-network-mln/mlnproducts/downloads/eval-mgmt-serv-guide-icn006764.pdf
- CMS. ICD-10-CM Official Guidelines for Coding and Reporting. Published online April 1, 2024. Accessed April 12, 2024. https://www.cms.gov/files/document/fy-2024-icd-10-cm-coding-guidelines-updated-02/01/2024.pdf
- Medical Billers and Coders. Who does the Coding for Physician Services? Medical Billers and Coders. Published February 7, 2020. Accessed April 11, 2024. https://www.medicalbillersandcoders.com/blog/who-does-the-coding-for-physician-services/
Debunking Regulatory Myths overview
Visit the overview page for information on additional myths.
Disclaimer: The AMA's Debunking Regulatory Myths (DRM) series is intended to convey general information only, based on guidance issued by applicable regulatory agencies, and not to provide legal advice or opinions. The contents within DRM should not be construed as, and should not be relied upon for, legal advice in any particular circumstance or fact situation. An attorney should be contacted for advice on specific legal issues. Additionally, all applicable laws and accreditation standards should be considered when applying information to your own practice.
