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Coding & Billing
Is Your Business Office in Shape?
Lolita Jones
Publish Date: October 10, 2007   |  Tags:   Financial Management

We know the revised ASC payment system is coming, we just don't know when. But why wait for CMS to officially announce the final rule to get your business office in tip-top shape? Here are 16 exercises to help you do just that.

1. Verify insurance coverage before you schedule. Do this for all patients before their procedures are ever performed. If possible, enter and scan the insurance verification data into your information system so that the entire business staff has electronic access to this data.

2. Code from the final operative report. Never bill using the codes provided for scheduling and insurance verification or the codes selected by the physicians without reviewing the final handwritten or transcribed procedure/operative report. Only the final report lets you assign codes that are both accurate and comprehensive.

3. Shorten transcription turnaround time. Investigate and correct any reasons for the delayed receipt of transcribed reports. These reports must be available in a timely manner if you expect your staff to code from the reports quickly.

4. Implement electronic billing. Electronic billing results in faster claims processing; real-time receipt of claims edits, warnings and denials; and the ability to scan and submit additional claims-required data (such as operative reports and itemized billing data) electronically.

5. Obtain and centralize copies of all facility contracts. Make sure you keep the facility and technical component contracts with third-party payers on file. These contracts are needed to ensure that the claims are paid according to the agreed-upon and negotiated contractual obligations.

6. Use cost data to re-negotiate contracts. Cost out each procedure that you perform by identifying all costs associated with each procedure, such as supplies, staff salary and overhead. When contracts are up for renewal, use this cost data to try to obtain carve-out payments for services such as fluoroscopic guidance. This is even more important if you'll be relying more on non-Medicare contracts to offset potential losses under the new Medicare payment system.

7. Document anesthesia compliance. Ensure that the documentation of the anesthesia administered is consistent within a single medical record. For example, a nurse's notes shouldn't reflect the use of local anesthesia for the patient's procedure when the anesthesia record or operative report denotes general anesthesia. Require the clinical staff to implement a process to ensure that this documentation is consistent throughout individual records and cases.

8. Audit a sample of cases. You'll want to audit for modifier, ICD-9-CM, CPT and HCPCS Level II coding accuracy. Verify the codes assigned against the official coding guidelines and the medical records documentation for the cases you review. A recent coding audit we performed identified

  • undercoding of multiple breast biopsies performed via separate incisions;
  • new technology intraocular lens (NTIOL) code Q1003 was billed but it wasn't supported by IOL brand and model data; and
  • no CPT code was reported for the wrist tendon transfer that was performed during the carpometacarpal arthroplasty.

9. Improve physician documentation. Correct any physician documentation issues you identified during the coding audit by educating your physicians. We found that surgeons inadequately documented the following clinical data during a recent coding audit:

  • collateral ligament ankle repair wasn't specified as primary versus secondary;
  • the "contracted toe" deformities weren't specified in more detail (for example, hammer toe, claw toe or mallet toe)
  • the vein surgery documentation was unclear (was it stab phlebectomy or varicose vein stripping and ligation?)
  • the specific number of warts destroyed wasn't documented;
  • the specific tendon (extensor versus flexor) that the surgeon released and lengthened wasn't stated;
  • the specific site of an ulnar fracture (distal or shaft?) wasn't specified; and
  • the size wasn't reported for each bladder tumor treated endoscopically.

10. Revise your charge sheet/Superbill. The 2007 ICD-9-CM coding changes took effect on Oct. 1, 2006, and the 2007 CPT and HCPCS Level II code changes took effect on Jan. 1. Make sure that the your charge sheet/Superbill doesn't contain codes that have been deleted or updated in the current coding books.

11. Properly document epidurography. Per the CPT code book guidelines for code 72275 (epidurography, radiological supervision and interpretation), you must keep a copy of the image on file and document a formal report to code and bill for an epidurography. Here's an example of an epidurography formal report:

"Epidurogram: There was good speed into the epidural and thoracic space. You could see the dye both ventrally as well as dorsally. No signs of obstruction noted. This is a normal epidurogram. In the lumbar, also no signs of obstruction. You could see the dye superiorly and inferiorly at the L3-L4 level and also at the L5-S1 level. Dye spread was mainly posteriorly in the dorsal epidural space. No signs of obstruction noted. A total of 4cc of Isovue dye was given."

12. Report secondary diagnosis codes. Require your coding staff to report diagnosis codes for co-existing conditions, as these conditions frequently support the medical necessity for additional surgical procedures that are performed. For example, an arthroscopic meniscectomy (CPT code 29881) procedure would be medically necessary for a meniscal tear, but another diagnosis, such as synovitis, would be needed to support an arthroscopic major synovectomy (CPT code 29876) that's also performed during the same encounter.

13. Report modifiers when applicable. Not all third-party payers require such modifiers as FA to F9 (fingers), TA to T9 (toes) and ?59 (distinct procedural services), but this data can be very valuable for internal data analysis. Report modifiers for all cases - even if the modifiers will be suppressed on the bill - so that you have this data on file.

14. Consistently code shoulder tears. What's your policy for coding a current/acute tear versus chronic rotator cuff tear? The diagnosis and CPT procedure codes vary for these conditions, and it's critical that staff consistently report these codes based on your facility's policy. The diagnoses should also agree with the procedures; a chronic rotator cuff tear procedure code should be linked to a chronic rotator cuff tear diagnosis code. Some orthopedic surgeons state that a chronic rotator cuff tear is any tear that is "degenerative" in nature.

15. Report the correct units of service. Since Ambulatory Payment Classification group assignments are triggered for each unit of service reported on CMS-1500 claims, you must make sure that the units reported next to a CPT code accurately reflect the services rendered.

16. Implantable devices. Assign HCPCS Level II codes for implanted prostheses and devices. Although most implanted devices will be packaged (not separately reimbursed) under APCs, this data is still valuable for secondary payers that may reimburse these items separately. Some commonly reported codes:

  • E0782 (Infusion pump, implantable, non-programmable [includes all components, such as pump, catheter and connectors])
  • L8600 (Implantable breast prosthesis, silicone or equal)
  • L8612 (Aqueous shunt)
  • L8680 (Implantable neurostimulator electrode, each) and
  • L8686 (Implantable neurostimulator pulse generator, single array, non-rechargeable, includes extension).