CLEAN CLAIMS Ensuring the accuracy of every claim you submit goes a long way toward ensuring you're fully reimbursed.

As one of the highest-volume multi-specialty ambulatory surgical centers in Virginia, we're always doing the legwork — and, in some cases, the detective work — to make sure we properly code every procedure. After working so hard to bring patients through the door, we don't want to leave a dime we're entitled to on the table. Here are 4 tactics that have worked well for us.

1Compare the facility bill to the op report. When you analyze the facility bill against the surgeon's operative report, it's not so much about correcting incorrect billing; it's about identifying any codes that were left out because the op report wasn't as specific as it needed to be. The op report might say one thing and one thing only, but by looking at each of the steps the surgeon took, including analyzing the materials he used, you might find 5 or 6 other "hidden" codes. Performing comparison audits can uncover CPT codes that you otherwise wouldn't have billed. Each unbilled code you miss and don't bill for represents a lost opportunity, dollars that should have gone to your bottom line.

2The more specific, the better. When it comes to surgical documentation, specificity is your best friend. Learn the types of procedures your doctors are performing and know the proper codes associated with those procedures. Make sure your docs know them, too.

Let's use a retinal detachment case as an example. What type of retinal detachment was it? What type of membrane was removed? If you don't properly document those things, you need to ask follow-up questions, because the codes for each of those things are different — as are the reimbursements.

As an example of omission, let's say an orthopedic surgery op report mentions internal fixation, but there's nothing listed for fixation on the surgeon's bill. It might be something as simple as a screw — another $300, perhaps — that you'll find as a result of the audit. This found money adds up quickly.

If performed well, a comparison audit can improve relations and build solidarity between the surgical center, physicians and their offices, as well as among all departments involved in the reimbursement process. But it all begins with the surgeons practicing good documentation — and sometimes that can be a challenge. Physicians tend to get used to doing things their way, which might include using unspecified codes, and now here you are coming in and telling them, "We need you to change." Those can be delicate conversations, but there are certain ways to frame those discussions in which you can become an ally. By telling them, "These are 1 or 2 small steps you can take to maximize the bottom line," you're essentially helping that person increase their financial security without any compromise to patient care or legality.

3Get retroactive authorization. Sometimes a physician will post a case based on what he anticipates he's going to do in the surgery. If things change in the course of a surgery and the surgeon has not communicated any additions he might have done, your business office needs to go back and get retroactive authorization for the procedure. If it's documented in the chart but not the op report, have the surgeon amend the op report. Otherwise, you can't bill for it, so you're basically performing an additional procedure — having already incurred the cost — without any reimbursement.

This happens in a lot of cataract surgeries. Most cases of anterior vitrectomy are unplanned, but if we're able to catch and bill for the "planned anterior vitrectomy," the reimbursement will make up for other non-billable services. For example, a Malyugin ring, which is used to retract and support the iris during small-pupil cataract cases, is non-billable and it costs the surgical center about $790. Billing for the anterior vitrectomy will help the facility minimize or eliminate the overall loss in cases like this.

4Cultivate champions. Our lead orthopedic nurse, Elizabeth, is our go-to expert — our champion, if you will — in orthopedics. She can recite every preference card and knows what will be needed with just about every orthopedic procedure. She can work with materials management before surgery to make sure all the necessary implants and supplies have been ordered and accounted for. And she can work with the billing and coding folks to make sure the op report is in order so we can account for every dollar. You need an Elizabeth at every level.

We have to be financially smart if we are to continue serving our patients in the best way possible. That includes making sure every member of your team is pulling in the same direction. From the surgeon to the surgical support staff to your colleagues in coding and billing, everyone needs to be focused on common goals, both clinically and financially.

Yes, delivering the highest-quality care to our patients is without question our No. 1 priority, but we also need to fund the delivery of that care by ensuring the accuracy of every claim we submit. We must be as energetic and vigilant about nurturing our profits as we are about caring for our patients.

Quality coding
The importance of quality coding has never been more apparent. Commercial carriers are reviewing submitted claims more stringently and denying reimbursements for not including the appropriate procedural code. Then there are deficiencies in surgical documentation. Whether it's a surgeon not complying with the ICD-10 diagnosis codes, forgetting to document some of the small but important steps he took in the course of a procedure, or some other factor, those deficiencies can bear a price — it could be thousands of dollars per patient — in terms of delayed (if not lost) revenue. OSM