Coding & Billing: 3 Reimbursement Traps to Avoid

I’m not saying you must become a reimbursement guru, but in the business of surgery, where your revenue is generated by how you code your cases, you should at least have a solid grasp of the complex world of CPT coding. Otherwise, you won’t capture all of the revenue to which you’re entitled. A good place to start is avoiding these 3 common reimbursement traps.

1Not staying current on CPT codes. CPT procedure codes are updated annually. If you don’t keep up with the yearly changes, you’ll likely leave money on the table. Take, for example, C9290, the product-specific HCPCS code for Exparel (liposomal bupivacaine) that took effect Jan. 1, 2019. CMS temporarily gave Exparel “pass-through” status — separate reimbursement from bundled surgical supplies for at least 2 but not more than 3 years to encourage the use of innovative drugs, devices or biologicals — from 2012 to 2014 in both the hospital outpatient and ASC settings. When CMS withdrew pass-through status for Exparel in both settings, usage, as you might expect, declined by 70% once facilities could no longer bill for the post-surgical anesthetic with an average wholesale price of $285 for a 20-mL vial. Now, however, as an incentive for using non-opioid pain medications, Medicare will provide separate reimbursement for Exparel when it is administered in ASCs (yes, surgery centers only). For the 20-mL (266 mg) dose, the allowed amount for reimbursement is $319.20. For the 10-mL (133 mg) dose, the allowed amount for reimbursement is $159.60. Imagine the losses you’d incur if your coder didn’t know to use C9290 to bill for Exparel.

You’ll also want to look at your Category III codes, a set of temporary codes used for data-collection purposes with emerging technology, services and procedures. One example is 0474T, the code for inserting an anterior segment aqueous drainage device. Without explanation, Medicare will no longer reimburse for this code. If your surgeon inserts an anterior segment aqueous drainage device, CMS will assign an E5 payment status indicator to that 0474T code. The indicator states that the procedure is a “surgical procedure/item not valid for Medicare purposes because of coverage, regulation and/or statute; no payment.”

If you didn’t know about this Medicare policy change, it’s possible you’d go months before you realized you’re not getting paid for this procedure. In this example, not only would you lose out on the revenue from the procedures, but you’d also be on the hook for the $2,040 drainage device.

2Upcoding new technologies. Be skeptical when vendor reps of new minimally invasive technology say you can apply more extensive CPT codes. Let’s say a physician inserts an implant for nasal vestibular lateral wall stenosis. A rep might tell you it’s OK to code with the higher-paying CPT code of 30465, which is for a full repair of nasal vestibular stenosis. That’s not correct. You should use HCPCS code C9749, a code for a far less extensive procedure.

Remember, the CPT code is based on the amount of time and work a procedure is expected to take. Many of today’s new devices and technologies greatly reduce the time and surgical effort it takes to perform a procedure.

3Ignoring your carrier policy. If you outsource your billing to a third-party firm, keep in mind that the billing company’s job is to maximize reimbursement on each case that it bills. However, the billing practices must follow the policies of the carrier with which you’ve contracted. For example; if you have specific procedures — say a glaucoma stent procedure — that your major carriers such as Aetna and Cigna consider experimental, then it stands to reason that many of your other carriers will follow suit. It’s incumbent upon your billing company to determine every carrier’s payment policy. Remember: Billing is a specialized field, not just a data-entry position.

When reimbursement problems arise, my philosophy has always been, if you’re running a business, and your revenue is generated by how you code, then you owe it to your facility to educate yourself on the subject. Following this philosophy has proven very successful throughout my career in assisting others with reimbursement challenges. OSM