Obtaining maximum reimbursement for your facility and maintaining compliance in coding and billing often requires your coder to walk a veritable tightrope. Your facility expects to be reimbursed for all services performed, just as the physicians expect payment for the services they provide. While it is the responsibility of the facility's coder to interpret operative reports and assign appropriate diagnostic and procedural codes, documentation must support all services billed by both parties. If the physician bills for services that vary from those submitted by the facility, this could raise a red flag with payers.
One of the main reasons for coding variations between your center and the physician is lack of supporting documentation. This often leads to billing noncompliance, increased denials and incorrect claim payments. It is important that physicians and their office staff understand how inaccurate or insufficient documentation affects the facility's reimbursement.
How does your coder handle these problems and questions?
- The operative note does not contain enough information to accurately assign a diagnostic or procedural code for the services performed.
- The operative note can be interpreted several ways. How does your coder decide on code selection?
- Who does your coder turn to for further clarification of what services were provided?
- What is your facility's position when you find the physician's office has assigned codes that do not appear to be supported by the documentation, or find that it did not bill for all the services indicated in the documentation?
Here are some tips to ensure your facility and your physicians receive maximum reimbursement and stand united in terms of proper documentation, coding and billing:
Develop a line of communication between your facility and the physician's office staff. This networking is an important step in making sure that your coding and billing match that of the physician provider.
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A Matter of Interpretation
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You could code this case a number of ways, according to what is - and what isn't - included in this operative note. Here are a few examples:
- Documentation in title or body of operative note does not support findings. Was a polyp removed? If so, how was it removed? Which areas were biopsied and studied?
- If you code from title and details of the procedure, you might use these codes:
' 43235 (diagnostic EGD)
' 45378 (diagnostic colonoscopy)
- If you code from findings and recommendations, you might use these codes:
' 43239 (if biopsies were done during the EGD)
' 45385 (if polyp was removed via snare) and 45380 (if biopsies were done during colonoscopy and done in area other than polyp removal), using modifier '59 (distinct procedural service) may be carrier-specific
' 45384 (if polyp was removed using hot biopsy forceps)
- Nothing in body of operative note indicates that patient needed any of these things.
MAIN STREET SURGERY CENTER OPERATIVE RECORD |
Surgical Guest Name: |
Chart #: |
Surgeon: |
DOS: |
Title of Operation:
Esophagogastroduodenoscopy and Colonoscopy |
Medications:
Fentanyl 175mcg and Versed 8mg |
Indications:
Gastroesophageal reflux disease, dyspepsia and colon screening |
Details of the Procedure:
After informed consent was obtained, the endoscope was inserted into the oropharynx all the way down to the second portion of the duodenum. Upon withdrawal, retroflexion was performed in the stomach with good visualization.
The patient was repositioned and the colonoscope was inserted to the level of the cecum. The cecum landmarks were identified including the appendiceal orifice. The scope was then withdrawn to the level of the rectum. |
Findings:
1: Hiatal Hernia
2. Gastritis
3. Polyp in the ascending colon, approximately 6mm, and was removed and biopsies obtained
4. Diverticulosis |
Recommendations:
1. Follow up on biopsy results
2. Depending on pathology, the patient will probably require a surveillance colonoscopy in five years
3. PPI therapy; increase Nexium to 40mg b.i.d. |
Signature of Physician: |
Date: |
Abc/de
D: 08/06/2003 09:03:54
T: 08/06/2003 17:08:49 |
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Code only from a dictated or hand-written operative report and any other pertinent reports, including history and physical, pathology, radiology and intra-operative nursing note. By reviewing all documentation pertinent to the procedure, you may find your facility provided services not mentioned in the operative note.
Communicate your findings to the physician for clarification. Be prepared to provide specific information, including documentation guidelines, interpretation differences and lack of diagnosis.
When necessary, request an addendum to the operative report to provide clarification of services provided.
From an efficiency standpoint, we highly recommend that you establish an easily accessible but secure area in the facility for physicians to retrieve medical records that have documentation discrepancies or coding queries.
Provide continuing education. Your facility should be providing in-services to keep pertinent staff current on the latest guidelines that pertain to documentation, coding, billing and reimbursement. Invite the providers and their office staff.
Perform routine audits. These audits should include the services billed by your facility and the services billed by the physician.
Discuss any discrepancies found in audits with the physicians and/or their office. Working together, you can establish guidelines to prevent future errors. When auditing errors are found, request addendums to documentation and submit corrected claims when necessary.
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How to Bill for Non-Medicare ASC List Procedures
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In an ideal world, surgery centers would be able to perform any clinically safe outpatient procedure and get paid for it, whether the patient is insured privately, by a managed care company or by Medicare. But ASCs must live with the reality of a limited Medicare ASC procedure list that, while finally expanded, omits many procedures that ASCs regularly provide non-Medicare patients. Here are four guidelines for hosting non-ASC list procedures without violating Medicare rules and regulations.
1. Understand physician reimbursement. While Medicare won't pay you a facility fee for such a procedure, it will pay the surgeon a physician fee. This fee is paid at the non-facility (in-office) rate set by Medicare's physician fee schedule. These fees are usually, but not always, higher than the in-facility rate because they include payment for practice-related expenses (despite the fact that, in this case, the ASC, not the surgeon, incurs all of the equipment, supply, staffing and other practice-related overhead). To determine if there is a higher in-office rate for a particular procedure, go to writeOutLink("cms.hhs.gov/providers/pufdownload/99carr.asp",1).
2. Bill the physician, not the patient. When Medicare pays the physician the in-office rate for performing the procedure, Medicare has made it clear that you can't bill the patient (even if you provide the patient an advance beneficiary notice alerting him that Medicare won't pay you a facility fee). Medicare believes that the reimbursement provided the physician covers the total cost of providing the procedure.
That doesn't mean that you can't get paid. In fact, you can - and arguably must - bill the surgeon. Letting a physician perform, in your facility, procedures that Medicare is paying him for in order to cover the services you provide could be deemed by the Office of Inspector General an illegal kickback to bring cases to your ASC
What do you charge the physician? FASA suggests that you bill the physician the difference between Medicare's facility rate and the non-facility rate. This is one recommendation and you can determine what to charge in a different manner. However, you must apply the same fair market value standards for the fee schedules you charge all physicians doing non-list cases.
3. The multiple-procedure conundrum. What if a surgeon does multiple procedures in one session, with at least one not on the ASC list? For example, an orthopedic surgeon may perform on the same knee two procedures - one on the Medicare list, the other not. It would be inconvenient to the surgeon (and detrimental to the patient) to schedule a second surgery in the office strictly for Medicare reasons. You can bill Medicare for the list procedure but not the non-list one. However, for the procedure on the Medicare list, the surgeon gets paid the facility rate (Medicare pays the surgeon the higher non-facility rate for the second procedure). If you don't collect the fair market value for the second procedure, you've arguably given the physician an inducement to bring the first procedure to your facility. Bill the physician for the second procedure using the differential described above. Use Medicare's normal rules for determining which procedure is paid 100 percent and which at 50 percent (the highest rate procedure is paid 100 percent).
4. Be consistent. While you have some flexibility in determining what non-ASC list procedures you'll perform and how you'll establish the amount to bill physicians, be consistent. Variations of your payment schedules from one surgeon to the next can get you in hot water.
Ms. Bryant ([email protected]) is the executive director of the Federated Ambulatory Surgery Association.
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Medicare MD Payment Differentials
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Facility |
Office |
12001 Repair of superficial wounds |
$88.88 |
$162.66 |
21030 Removal of face bone lesion |
$326.44 |
$357.32 |
28124 Partial removal of toe |
$548.08 |
$615.85 |
67101 Repair detached retina |
$680.99 |
$769.78 |
68530 Clearance of tear duct |
$275.39 |
$739.06 |
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NOTE: Figures reflect physician Medicare payments in the Washington, DC area.
SOURCE: FASA
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Track unbilled procedures due to lack of or insufficient documentation and share this report with your team.
Provide your facility's administrative leaders with documentation regarding physician documentation of non-compliance so the whole team is aware of this problem and can take steps to correct it.
Maximizing reimbursement
Through open communication with your facility's physician providers and their offices, you can keep coding and billing discrepancies to a minimum and maximize reimbursement for both parties - while still maintaining compliance with government and payer regulations and requirements.
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