Coding News, Tips & Updates
2010 Coding News, Tips and Updates
- CMS Seeks Input on Contractors
- CMS Announces Organizational Restructuring
- Category III Codes and Pain Medicine Procedures
2009 Coding News, Tips and Updates
- 2010 Medicare Physician Fee Schedule Released by CMS
- November is Heal that Claim™ Month!
- Transforaminal Injections and The Office of Inspector General (OIG)
- Understanding Medicare's National Correct Coding Initiative (NCCI)
- Recovery Audit Contractors (RAC) and You
- Understanding Medical Necessity and Payers
- Understanding the Advanced Beneficiary Notice (ABN)
- Examine Your Practice
- Access Your Payer's Report Card
Managing the Claim:
- Step 1: Scheduling and Registration
- Step 2: The Clinical Encounter
- Step 3: Generate the Claim
- Step 4: Internal Auditing
- Step 5: Know Your Financial Health
- Step 6: Identifying the Issue
- Step 7: Preparing to Appeal
- Step 8: Developing an Effective Appeal
2008 Coding News, Tips and Updates
2010 Coding News, Tips and Updates
By Emily Hill, PA
CMS Seeks Input on Contractors
March 12, 2010 -- CMS has randomly selected 30,000 fee-for-service (FFS) physicians, suppliers and other health care professionals to participate in the 2010 Medicare Contractor Provider Satisfaction Survey (MCPSS). This is the 5th survey initiated by CMS as a means to evaluate and improve the services provided by its FSS contractors. Medicare contractors are responsible for performing the operational aspects of the Medicare program.
The survey addresses 7 key areas:
- Provider Inquires
- Provider Outreach & Education
- Claims Processing
- Appeals
- Provider Enrollment
- Medical Review
- Provider Audit & Reimbursement
The survey is web-based and uses a labeled 5-point system. CMS will release a summary report on its website in the summer of 2010. Selected providers were notified in January 2010. Selected physicians are urged to respond to the survey. Although only selected providers can complete the survey, a sample questionnaire is available for informational purposes at http://www.cms.hhs.gov/mcpss.
CMS Announces Organizational Restructuring
February 26, 2010 -- The Centers for Medicare and Medicaid Services (CMS) has announced a reorganization creating four Centers: Medicare; Medicaid, CHIP and Survey & Certification; Center for Program Integrity; and Center for Strategic Planning. Each Center will be led by Deputy Administrators who will report to the Administrator. The Center for Medicare will combine Medicare fee-for-service, managed care, and the prescription drug benefit into one Center that will report directly to the Administrator. The Center for Program Integrity will realign the current Medicare and Medicaid integrity units into a single Center and be renamed the Medicare Program Integrity Group and the Medicaid Program Integrity Group respectively.
CMS states the realignment will allow the Agency to better focus on three key areas: beneficiary services, program integrity, and strategic planning. In addition to the four Centers, the new structure will establish the position of Principal Deputy Administrator and the Office of External Affairs and Beneficiary Services. Although not yet approved by the Secretary, it is expected that the plan will be approved and implemented within the next 60 days.
Charlene M. Frizzera will continue to serve as CMS Acting Administrator until a permanent appointment is named.
Category III Codes and Pain Medicine Procedures
February 9, 2010 -- Category III codes recently have been approved for paravetebral facet and transforaminal epidural injections using ultrasound guidance. The codes are formatted in a manner similar to the corresponding Category I codes (64479-64484 and 64490-64495), which describes procedures in which the guidance employed is either fluoroscopy or CT. The table below describes the procedure, the implementation date, and the year they will appear in CPT.
Category III codes are a set of temporary CPT codes to describe emerging technology, services and procedures. The codes are alphanumeric and use 4 digits followed by the letter "T." These codes allow the collection of specific data used to assess the clinical efficacy, utilization and outcomes of the described services. Once there is adequate data on the safety and efficacy of the use of ultrasound with facet and transforaminal injection procedures, the codes can be considered for Category I status. Category III codes that do not meet Category I criteria typically are archived after five years.
Category III codes are updated quarterly and posted on the AMA/CPT website. They are not assigned relative value units (RVUs). Payers, including Medicare, will determine reimbursement for these services on a case-by-case basis.
|
Implementation Date: January 1, 2010 Publication Date: CPT 2011 |
|
| CPT Code |
Description |
| ●0213T |
Injection(s), diagnostic or therapeutic agent, paravertebral facet (zygapophyseal) joint (or nerves innervating that joint) with ultrasound guidance, cervical or thoracic; single level (To report bilateral procedures, use 0213T with modifier 50) |
| +●0214T |
second level (List separately in addition to code for primary procedure) |
| +●0215T |
third and any additional level(s) (List separately in addition to code for primary procedure) |
| +●0216T | Injection(s), diagnostic or therapeutic agent, paravertebral facet (zygapophyseal) joint (or nerves innervating that joint) with ultrasound guidance, lumbar or sacral; single level (To report bilateral procedures, use 0216T with modifier 50) |
| +●0217T |
second level (List separately in addition to code for primary procedure) |
| +●0218T |
third and any additional level(s) (List separately in addition to code for primary procedure) |
|
Implementation Date: July 1, 2010 Publication Date: CPT 2011 |
|
| CPT Code |
Description |
| ●0228T | Injection(s), anesthetic agent and/or steroid, transforaminal epidural, with ultrasound guidance, cervical or thoracic; single level |
| ●0229T |
each additional level (List separately in addition to code for primary procedure) |
| ●0230T | Injection(s), anesthetic agent and/or steroid, transforaminal epidural, with ultrasound guidance, lumbar or sacral; single level |
| ●0231T |
each additional level (List separately in addition to code for primary procedure) |
2009 Coding News, Tips and Updates
By Emily Hill, PA
2010 Medicare Physician Fee Schedule Released by CMS
November 13, 2009 -- The Centers for Medicare and Medicaid Services released the 2010 Medicare Physician Fee Schedule (MPFS) on Friday, October 30. Included are several provisions of importance to Pain Medicine Physicians. Impacting all physicians is the proposed 21.2% reduction in the dollar conversion factor for 2010. Current law requires CMS to adjust the MPFS payment rates annually based on an update formula which requires application of the Sustainable Growth Rate (SGR) adopted in the Balanced Budget Act of 1997. This formula has resulted in negative updates since 2003, although reductions have been avoided by CMS administrative adjustments and legislative actions for each year through 2009. Recent legislation to eliminate the SGR formula was blocked, primarily by Republicans, and failed to pass the Senate. The AAPM will continue to monitor the situation and keep members apprised of pending legislation impacting 2010 reimbursement.
On a more positive note, CMS has proposed to remove physician-administered drugs from the definition of "physicians' services" for purposes of computing the physician fee schedule update. This will have a positive impact on future payment updates beginning in 2011.
Another positive change for Pain Medicine physicians is the provision to include recent data about physicians' practice costs from a new survey, the Physician Practice Information Survey (PPIS) into the calculation of Practice Expense (PE) RVUs. The AAPM participated in the PPIS survey which was developed by the AMA. CMS estimates the impact of the PE changes to Pain Medicine and Interventional Pain Medicine physicians as follows:
| |
Previous Indirect PE/Hour | Proposed Indirect PE/Hour | Previous Indirect% | Proposed Indirect % |
| Pain Medicine | $59.04 | $122.42 | 67% | 70% |
| Interventional Pain Medicine | $59.04 | $156.79 | 67% | 70% |
The change will be incorporated into the Fee Schedule over a 4-year period and will be apportioned by code based on the percentage of specialties performing a given procedure.
Other changes include a proposal to stop paying for consultation codes and to redistribute the resulting savings to increase payments for the existing evaluation and management (E/M) services. Payments for the surgical global period will be adjusted to reflect the higher value of the office visits furnished during the global period. CMS is also proposing revisions to the Electronic Prescribing Incentive Program (e-Prescribing Program) and the Physician Quality Reporting Initiative (PQRI).
AAPM will continue to analyze the proposed changes and the impact on Pain Medicine Physicians. For those interested in reading the Final Rule prior to publication in late November, you can find it at: www.federalregister.gov/OFRUpload/OFRData/2009-26502_PI.pdf
November is Heal that Claim™ Month!
October 30, 2009 -- Throughout 2009, AAPM has provided tips and information on managing the claims and reimbursement processes in your practice. This November, join physicians nationwide in the AMA's "Heal that Claim™" month, part of an ongoing campaign to eliminate waste in the claims process. The "Heal the Claims Process™" campaign calls on all participants in the health care claims process - physicians, their practice staff, and their billing partners; payers; employers; and patients—to do their part by committing to efficiencies and getting it right the first time. Be a part of the solution. Help heal the claims process by streamlining your claims process, reviewing and reconciling claims payments, and evaluating your practice management system to prepare for the approaching 5010 and ICD-10 mandated updates and use of electronic transactions. Get started by visiting the AMA's Practice Management Center at www.ama-assn.org/go/pmc for resources that can help.
Transforaminal Injections and The Office of Inspector General (OIG)
October 30, 2009 -- The OIG posted its 2010 Workplan and states it plans to review claims for transforaminal injections to determine the appropriateness of Medicare payments for these services. The Workplan sites an increase in physician claims for these services of 130% between 2003 and 2007. The review will focus on whether the services were "reasonable and necessary" and whether policies and safeguards are in place to prevent inappropriate payments.
Each year the OIG releases its Workplan which describes the specific audits and evaluations that it plans to initiate or continue with regards to the programs and operations of the Department of Health and Human Services (HHS). In addition to other areas, the Workplan specifically looks at issues impacting CMS (Centers for Medicare and Medicaid Services) including those areas involving physician services.
Pain Medicine physicians should be diligent in documenting the patient’s presenting problem, previous interventions (surgical and non-surgical), and the patient’s response to previous and current treatment regimens.
The entire 2010 Workplan and previous Workplans can be accessed online at: http://oig.hhs.gov/publications/workplan.asp.
Understanding Medicare's National Correct Coding Initiative (NCCI)
October 2, 2009 -- The Correct Coding Initiative (CCI) is CMS’s attempt to standardize the bundling practices of its carriers and to control improper coding and payments. The guiding principle of the CCI is that all services integral to accomplishing a procedure are bundled into the primary service. Therefore, these services are considered components of the comprehensive code. Under the CCI, a service is considered bundled into another procedure when the service: Represents the standard of care in accomplishing the overall procedure; Is necessary to successfully accomplish the comprehensive procedure; Is not a separately distinguishable procedure when performed in conjunction with the comprehensive service. There are two CCI edits tables: Column One/Column Two Correct Coding Edits table and the Mutually Exclusive Edits table. These tables contain pairs of CPT and/or HCPCS codes that ordinarily are not separately payable. CMS recognizes that under some circumstances, it may be appropriate to report separately codes that are generally considered bundled. Certain modifiers ( 25, 58, 59, 78, 79, and 91) are designated to be used with the CCI code pairs in these cases. Some edits can never be overridden by use of any of the CCI modifiers. CCI edits are applied to services billed by the same provider for the same patient on the same date of service. All Medicare claims are processed against the CCI edits. Services denied based on CCI edits may not be billed to Medicare beneficiaries under any circumstance.
CCI policies and edits represent CMS national policy. The code pairs are developed based on CPT coding conventions, Medicare national and local policies and edits, coding guidelines developed by national societies, analysis of standard medical and surgical practices, and a review of current coding practices. It is important to recognize that the CCI does not include all possible combinations of edits. The absence of a specific edit should not be interpreted to mean that a particular code combination represents correct coding.
The CCI is updated quarterly and seeks input from the medical community. The AAPM Coding and Reimbursement Committee reviews all proposed edits and provides feedback on those edits impacting Pain Medicine physicians. AAPM can recommend an edit be implemented as proposed, implemented but with a change in modifier requirements, or deleted. Although recommendations from the AAPM have been accepted for certain code edits, CMS makes the final determination on whether an edit is implemented. Information on the process and the updated edits are available on the CMS website at: http://www.cms.hhs.gov/NationalCorrectCodInitEd/
Recovery Audit Contractors (RAC) and You
August 21, 2009 -- Most physicians and practice staff have heard about the "RACs". But what does it really mean to the average practice? Congress mandated the RAC program as part of the Medicare Modernization Act of 2003 and funded a 3-year Demonstration Project. The Centers for Medicare and Medicaid (CMS) contracted with private entities to detect and correct improper payments. The contractors were instructed to identify both underpayments and overpayments. Repayments were collected from providers for overpayments and refunds given to providers for underpayments. In instances in which both over and underpayments were identified, the provider's liability was reduced by the amount of underpayments identified. The RAC contractors were paid a contingency fee for identified over and under payments. The vast majority of improper payments were associated with inpatient hospital services. Physician services accounted for only 3% of the overpayments.
The Tax Relief Act of 2006 required a permanent program by 2010 that covered all 50 States. Four RAC jurisdictions have been established that match the current MAC (Medicare Administrative Contractors) areas. Contractors have been identified for each RAC jurisdiction. Subcontractors will be used to supplement the efforts of each of the four RACs.
The RACs do not replace other review activities but will not include claims previously reviewed by other review mechanisms. The RACs will use the same policies as carriers and other CMS entities. All reviews will be on a post-payment basis and will be restricted to 3 years prior to the date the claim was paid. The current Medicare appeal process will be used for RAC appeals except that the RAC process provides the opportunity to discuss the determination outside the appeal process.
Two types of reviews will be conducted: automated and complex. Automated reviews do not require medical records and will be allowed only when: 1) a clear policy exists as the basis for the overpayment, 2) the review is based on a medically unbelievable edit, or 3) a timely response (45 days) has not been received following a medical record request.
Limits, based on the size of the medical entity, are placed on the number of medical records that can be requested in a 45 day period. The RACs are required to use clinical personnel to conduct the record reviews and must employ certified coders, nurses, therapists, and a physician. A Review Board has been established to provide oversight of the RAC activities and a Validation Contractor identified to provide annual accuracy reports. The RACs will be paid a contingency fee for the accurate identification of improper payments.
The RACs will use proprietary software, OIG and CMS reports, and findings from the Demonstration Project to identify issues for future RAC review. A phase-in strategy has been developed by CMS based on the type of review. Provider outreach must occur in each state prior to initiating a review. In addition, review issues must be first approved by CMS and posted on the RAC website. RAC websites are scheduled for implementation by January 2010. Additional information on the RAC process and the phase-in strategy can be found at www.cms.hhs.gov/RAC.
Understanding Medical Necessity and Payers
June 23, 2009 -- The term medical necessity can be defined or interpreted in many ways. The AMA's Model Managed Care Contract defines medical necessity as health care services or procedures that a prudent physician would provide to a patient for the purpose of preventing, diagnosing, or treating an illness, injury, disease or its symptoms in a manner that is:
- In accordance with generally accepted standards for medical practice;
- Clinically appropriate in terms of type, frequency, extent, site, and duration; and
- Not primarily for the economic benefit of the health plans and purchasers or for the convenience of the patient, treating physician, or other health care provider.
Payers may have different definitions or have certain procedures that must be approved as "medically necessary" prior to payment. It is important that your office staff gets prior approval for all procedures and any specialized testing. Staff should also obtain information about covered diagnoses/conditions, any prior treatment or testing that must be initiated prior to approving the service, and any special reporting requirements. This information should be maintained in an insurer file for future guidance.
Denials on the EOB (Explanation of Benefit) often include terms such as "not medically necessary" or "not clinically indicated". In some instances, the denial code or remark might state that the service is "included in the payment" for another service. The first area to explore is the ICD-9-CM code(s) used. Payers generally utilize software programs that associate procedure codes with certain diagnoses felt to demonstrate the clinical need for a given procedure. In addition, most payers utilize only the first diagnosis associated with the procedure on the claim form to determine medical necessity. It is important, therefore, that care is taken when the claim is filed to ensure that each CPT code is supported by the diagnosis that most accurately describes the reason for the service. Physicians should clearly link the CPT and ICD codes on the encounter form so that staff can file the claim appropriately the first time. If the practice made an error in filing, the claim can be resubmitted as a corrected claim.
If the claim was filed correctly, you may wish to ask the patient if he/she has received a denial letter. The language in that letter may be helpful in determining a more precise reason for the denial. You may also wish to contact the payer for additional information prior to initiating a formal appeal. You should seek to obtain the payer's definition or clarification of medical necessity, the source and content of any information the payer might have used in its determination (including expert reports), and the information necessary to get the service approved. Based on this information, the practice must decide whether to move forward with the appeal.
Denials based on medical necessity often are the most difficult to appeal because of the varying definitions and payer policies. It is important that the physician participate in the appeal process on these claims. It may be helpful to speak directly with the claim reviewer or even the insurer's Medical Director. The physician must be prepared to demonstrate the need for the service with documented clinical information that supports the efficacy and safety of the service for the patient's particular clinical situation.
Understanding the Advanced Beneficiary Notice (ABN)
May 1, 2009 -- Medicare statute requires that beneficiaries be informed of their potential liability for payment of services under certain conditions. The Advanced Beneficiary Notice or ABN is the official CMS form used to document that notification. A revised form that also included a Notice of Exclusions from Medicare Benefits (NEMB) was implemented on March 1, 2009.
An ABN is used when the physician expects that a Medicare covered service may be denied because of coverage criteria (eg, frequency of coverage, diagnosis restrictions, or other payment limitations). If the physician practice fails to get a signed ABN, the patient cannot be held financially liable for the service in the event of a denial due to coverage limitations. The patient does not need to sign an ABN for services that Medicare never covers, such as cosmetic surgery, routine comprehensive physical examinations, and most screening tests. A physician can use the NEMB to voluntarily denote the patient's responsibility for payment for these non-covered services.
When an ABN is signed, the associated claim should be submitted with the appropriate modifier. In addition to notifying CMS of the situation, the modifier also results in certain language being generated on the patient's Explanation of Benefit (EOB) informing them of their financial responsibility. The modifiers are:
- GA modifier: if an ABN has been signed.
- GZ modifier: if an ABN has not been signed but should have been.
- GY modifier: if the service is not a covered Medicare benefit and the service is being reported to Medicare to receive a denial.
On April 14, 2009, Medicare issued a notice regarding an inappropriate use of the ABN with edits known as "Medically Unlikely Edits" (MUE). MUE edits are coding edits that limit the number of times (units of service) certain services can be reported on the same day by the same physician. According to Medicare statute, an ABN can be applied only if the initial determination on a claim results in a denial due to a medical necessity issue and not a coding edit. An initial claim determination based on MUEs is considered a coding edit and the ABN cannot be used to bill the patient. Likewise, the ABN cannot be used if a MUE denial is appealed and some units of service are deemed not medically necessary since an appeal is not an initial determination.
Additional information on the ABN and the MUE process can be found on the CMS website at http://www.cms.hhs.gov/BNI/02_ABNGABNL.asp and
http://www.cms.hhs.gov/MLNMattersArticles/downloads/MM5402.pdf.
Examine Your Practice
February 3, 2009 -- A successful medical practice involves more than providing quality patient care. It also means having management systems in place to address the financial aspects of a practice. Physician practices rely on reimbursement from third-party payers for most of its revenue. Successful management of a practice's reimbursement system involves effective and efficient processes for claims submission, follow-up, and appeals. If you can't answer the following questions, perhaps it's time to meet with your practice manager to better understand the reimbursement processes in your office.
- On average, how long does it take to submit a claim once the service is rendered?
- Are payments reconciled to each payer's fee schedule?
- What is the schedule for reviewing EOBs? Is there a list of denials maintained?
- What are your Gross and Net Collection Ratios?
- What are the average Days in A/R?
- Is there a log of follow-up calls to payers?
- Is there a written appeals process within your practice?
- Over the next several months, AAPM will be offering you tips and guidance to help ensure your practice is receiving all the reimbursement you deserve.
Access Your Payer's Report Card!
January 20, 2009 -- Assuming the payment from third-party payers is correct may cost your practice appropriate reimbursement. Even when you code your claim properly, payers may still deny or reduce payment or delay the reimbursement process. The American Medical Association (AMA) has launched a campaign called "Heal The Claims Process™" to help reduce the administrative burden of ensuring accurate insurance payments for physician services. With that initiative, the AMA has posted a National Health Insurer Report Card to provide physicians with a source of information on the timeliness, transparency and accuracy of claims processing by health insurance companies. The report card can be accessed at: http://www.ama-assn.org/ama1/pub/upload/mm/368/reportcard-short.pdf
Managing the Claim Step 1: Scheduling and Registration
February 17, 2009 -- An effective claims management process reduces administrative costs and helps reduce denials. The process begins with the practice's initial contact with the patient. It is important for scheduling staff to not only identify the reason for the visit but also to obtain initial patient demographics and health plan information. Appointment scheduling is the ideal time to advise the patient of the practice's payment policies. You may want to write a "script" for scheduling staff to ensure that the information is accurately and consistently presented to patients. Between the initial contact and the patient's appointment, the practice should verify the patient's insurance coverage, co-pay/deductible responsibility, and the plans referral and pre-authorization requirements.
At the time of the appointment, staff should have the patient complete a registration form that contains detailed patient demographics and insurance information. You may also want to provide the patient with a practice brochure that outlines general information about your practice as well as your payment policies. A copy of both sides of the patient's insurance card(s) should be retained in the file. If insurance verification has not been done, it should be completed at this time. At subsequent visits, the registration staff should routinely inquire about changes to the patient's health plan or insurance card. Accurate patient and insurance information is vital for obtaining payment from the health plan. It has been suggested that up to 30% of claim denials are due to improper patient and insurance information. These denials can be avoided by an effective and efficient registration process.
Managing the Claim Step 2: The Clinical Encounter
March 3, 2009 -- The claims management process is not limited to the office staff. Physicians and other members of the clinical staff have an integral role in ensuring reimbursement from the health plan. That involvement begins with the patient encounter. Appropriate documentation in the medical record is not only important for clinical care, it also helps diminish some of the obstacles that can occur with claims processing. It is important that the clinical documentation accurately reflect the CPT and ICD-9-CM codes being reported to the payer. From the payer's viewpoint, not documented means not done! A well documented encounter makes verification of billing codes easier for the practice staff. If an appeal is required, documentation that clearly supports the billing is essential.
The role of the clinical staff does not stop with the clinical note. Physicians and other providers should indicate on the encounter form (ie, superbill) the services (CPT codes) and the diagnoses (ICD-9-CM codes) applicable to the encounter. The claim must contain not only the service provided, but the specific reason for each service. The physician is the best source of that information. Therefore when more than one service is provided on the same day, the physician must link the CPT code with the specific ICD-9-CM code that supports the reason for that particular service. This can be done easily by assigning a common number to the associated CPT and ICD codes on the encounter form. Failure to appropriately correlate CPT and ICD codes is a common reason for denials.
Don't forget to update your encounter form or other coding sources annually. A list of the CPT and ICD changes for 2009 can be found here.
Managing the Claim Step 3: Generate the Claim
March 20, 2009 -- The first step towards ensuring timely and appropriate reimbursement is generating a complete and accurate claim based on the coding information provided by the physician. The staff assigned to completing the claim should be knowledgeable of coding guidelines and payer specific requirements. Regardless of whether the claim is filed on paper or electronically, it is essential that all required information be included and in the proper format. Instructions for the completion of the standard paper claim, known as the 1500 Claim Form, can be found at www.nucc.org. Despite these instructions, there may be payer specific requirements of which the staff must be aware.
Many practices file claims electronically and use either a billing service or a clearinghouse to submit the claim to the third-party payer. Often, either the practice's billing software and/or the clearinghouse will produce reports notifying the practice of clerical errors before allowing the claim to be submitted. Some practice management software will allow you to revise or create additional edits in an attempt to identify possible denials or other problems in advance. Sometimes these edits or programs are referred to as "scrubbers". It is essential that practice staff review these reports on a regular basis to avoid claims being suspended internally and thus never reaching the payer. Additionally, these reports can be used to correct errors made by practice staff, thus speeding up the claim submission process.
The frequency at which claims are submitted depends on the volume of patients seen, types of service provided, and any third-party payer requirements. Obviously, the sooner the claim is filed, the quicker the practice receives reimbursement for the services provided to the patient. However, the desire to get the "claim out the door" should not take priority over ensuring that the claim information is correct and properly formatted. An inaccurate claim will ultimately cost the practice timely revenue and additional costs associated with handling the denials and re-filing a corrected claim.
Managing the Claim Step 4: Internal Auditing
April 3, 2009 -- Errors on healthcare claims can cost a practice in revenue and additional time associated with handling denials and appeals. It might also mean recoupment of inappropriate payments by the third-party payer. The best medicine in this case is prevention! In addition to ensuring that the claim form is correctly completed prior to submission, practices need to make certain that the clinical information has been appropriately communicated to the staff submitting the claim. In addition, the claim must be supported by the documentation in the medical record to avoid either underpayments or overpayments. The best way to assess the process is to conduct an internal audit.
Practices should develop a plan for conducting random audits on a monthly or quarterly basis. Typically practices randomly select 5-10 encounters for the review. The records might be selected based on the physician, the payer, common denials, or areas with the highest potential for errors such as high level E/M codes. Regardless of the sampling plan, encounters for each provider should be reviewed at a minimum of each year. Staff with coding experience should compare the documentation in the record to the information recorded by the provider on the encounter or “superbill”. This information should then be compared to the actual claim that was filed. Any discrepancies should be indentified, documented, and an action plan for follow-up developed.
Follow-up is critical to avoiding potential errors in the future as well as ensuring the accuracy of current claims. A pre-payment audit provides the opportunity to correct any errors prior to submitting the claim. If the audit is conducted after payment has been received, the practice might need to consider submitting a revised claim.
In any event, each potential error should be reviewed and education provided to the physician or the staff member involved with the claim. Auditing staff should track errors to determine any patterns of concerns that need to be addressed with the entire practice. It is important that all errors and subsequent actions be documented and maintained. In the event of an external audit, it is important that a practice can demonstrate that the appropriate action was taken in response to any deficiencies or errors.
Managing the Claim Step 5: Know Your Financial Health
May 22, 2009 -- An effective claim processing and follow-up system uses information from the practice management system to identify the key payers and services that create denials or delayed payments. Reports should be produced monthly that identify all outstanding claims that are 30 days or older along with detailed information for each claim. That information should include the date the claim was filed, the codes reported, and the reason for the denial if one was received. Calls should be made on any claim for which a response from the payer has not been received. You should be aware of the prompt payment laws in your state and maintain a list of any claim that is not processed accordingly. Payers who consistently violate state prompt payment laws should be reported to your state insurance commissioner.
For services that have been denied by the payer, if may be helpful to generate a separate denial report. This report should contain the reason codes used by the payer to support the denial. You should investigate any denial code that suggests problems with the claim submission process. For example, if the denial indicates that information was missing from the claim or that the claim was a duplicate, that should be confirmed before assuming the denial to be accurate. If there is a problem with your internal process, you should take the opportunity to understand the source of the problem and take corrective action.
Denials relating to coding should also be investigated. If there are errors occurring in your practice, these should also be examined. Education for both physicians and staff is an important step towards rectifying the problem. Often mistakes occur from a misunderstanding or lack of knowledge about coding guidelines and conventions. The AMA and national specialty societies, such as AAPM, are valuable resources for obtaining current and accurate information.
In addition to the unpaid claims and denial reports, you should review monthly the Accounts Receivable (A/R) report. The A/R represents the amount of money owed to you. Most reports distribute that money over specific time periods (e.g. 0-30 days, 30-60 days, etc). Some reports calculate A/R from the date of service and other from the date the claim was filed. Obviously, you want most of your dollars in the 0-30 day range. The longer the money is owed, the more difficult it is to collect. You should watch the A/R overtime as one measure of your practice effectiveness in the claims submission process.
Managing the Claim Step 6: Identifying the Issue
June 9, 2009 -- Once a denial is received, it is important to identify the stated reason provided by the payer. The reason code, which appears on the Explanation of Benefit (EOB) will identify the reason for the denial. These might include processing errors made by either the physician practice or the payer, requests for additional information from the physician practice, coverage issues, or denials based on coding or medical necessity guidelines.
If the denial is due to an incomplete claim or a simple claims processing error, you should contact your representative to determine the appropriate way to resolve the issue. If additional information is required, that should be sent immediately following the payer’s guidelines and instructions. In some instances minor problems can be dealt with over the phone. Other issues may require that the claim be corrected and submitted for reconsideration. All claims resubmitted due to errors or denials should be identified as a resubmission to avoid having the second claim denied as a duplicate.
Claims denied for coding or medical necessity issues should be carefully reviewed and information gathered for an appeal, as appropriate. A common reason for denials is the payer’s failure to recognize certain CPT modifiers. Modifier 25 (Significant, separately identifiable E/M service) and modifier 59 (Distinct procedural service) are two modifiers that indicate that two or more services provided on the same day are distinct and should be separately reimbursed. When payers do not recognize these modifiers inappropriate bundling of payments can occur.
Prior to appealing the claim, the practice should make certain that the modifiers were used correctly and the documentation in the medical record supports the use of the modifier and that all services are clearly documented. Next the practice staff should review the payer’s payment policies with regards to these modifiers. Many payers now publish its most common payment policies on its website. Alternatively, you can ask the provider representative or call the provider relations number for the payer.
Inappropriate bundling also can occur when the payer utilizes software that causes the payment for one service to be included in the payment for another. This can result even in situations when a modifier is not required. As mentioned above, the practice should review the documentation and CPT guidelines for reporting multiple services prior to appealing the claim. In recent years, CPT has included more parenthetical notes and introductory language denoting coding guidelines for specific codes or code combinations. Medicare also publishes the Correct Coding Initiative (CCI) that identifies some of its bundling edits. While the CCI includes many edits related specifically to Medicare’s unique coding policies, it can also serve as a guide for staff as they assess managed care payer’s bundling practices.
In the next issue, we will discuss medical necessity denials and how to prevent and challenge them.
Managing the Claim Step 7: Preparing to Appeal
July 8, 2009 -- The most effective appeal is one that is based on an appropriate rationale that is clearly and effectively stated. The first step is to gather all the information you have collected about the specific health plan involved as well as your coding resources. You should look for payer specific medical policies or previous claims that support the services you submitted. These should be referenced in the appeal letter and attached as appropriate. Don’t forget to look for denials that were overturned by the payer on appeal.
You should also seek specific references in CPT or in publications from related specialty societies. Medicare’s Correct Coding Initiative (CCI) may also be a valuable resource for illustrating the appropriateness of certain code combinations. Review the operative/procedural note and make certain that the reported services are clearly described. If multiple codes were reported for the encounter, look to see if the operative report clearly describes the services as distinct and separate procedures. If in doubt, billing staff should seek the input of a physician.
Be aware of any modifier requirements for the code combination in question and check to see if the claim was filed correctly. If there was a filing error, then the claim should be re-submitted as a corrected claim rather than an appeal. Modifier 59 (Distinct Procedural Service) is used to indicate that a procedure is distinct and separate from other procedures reported on the same day. As discussed in previous articles, this modifier is not always recognized by payers. Providers should also be aware that it may not always be appropriate to append the 59 modifier, even though a resource such as the CCI might suggest it. The clinical documentation must support the distinct nature of the procedure. Although CPT describes a number of circumstances for which the modifier might be appropriate, Medicare allows its use only when the multiple services are provided on different anatomic sites or at separate sessions on the same day.
Once you have compiled your resources and verified the validity of your appeal, you’re ready to compose the appeal letter and begin moving it through the proper channels. In the next article, we’ll discuss how to develop an effective appeal and follow the steps of the appeal process.
Managing the Claim Step 8: Developing an Effective Appeal
August 7, 2009 -- Once you have collected all the pertinent claim information and gathered all your supporting documentation, it’s time to begin the appeal process. Your first attempt should be to contact your payer’s representative if you are a participating provider. In some instances, the representative will review the claim and contact the claims department directly for resolution or to obtain additional information regarding the denial.
If that does not resolve your issue, you should begin to develop your appeal letter. Be sure to include all the appropriate identifying information including the date of service and the reason for your appeal. The supporting information is critical for an effective appeal. Note the patient’s complaint and any personal comments by the physician with regards to findings and the clinical need for the service. You should also include your findings from the medical record review and the supporting documentation gathered in preparation for the appeal. The physician should review every appeal letter and provide additional clinical information to support the coding and the medical necessity of the service. All appeal letters should include the physician’s signature and credentials.
The letter should be addressed to an individual at the insurer’s office. If you do not have a name, obtain one from your payer representative or call the payer directly. You should also inquire about the expected time frame for the appeal to be processed. Also ask if there are any specific appeal forms that must be completed. If possible, fax the appeal to speed up the process. If not, mail the letter by certified mail with a return receipt requested. It is important to maintain documentation of all communications with the payer as you move through the appeal process.
Finally, you have to consistently follow-up with the payer until there is resolution of the claim. Document in a log all your communications and maintain copies of letters, emails, and supporting information for your files. Remember, you may ask for a physician of the same specialty to review the claim. Ask if a telephone review is possible to expedite the process and save on the costs of written appeals. The physician appealing the claim should be available to talk with the physician representative from the insurance plan.
Most payers have formal appeal processes that are posted on its website or included in your contractual agreement. The AMA has sample appeal letters based on the type of denial available on its website at: http://www.ama-assn.org/ama/pub/physician-resources/solutions-managing-your-practice.shtml under the section on Physician Resources. It is helpful to maintain a file of available resources and the outcome of previous emails to use in the future. The more information you have at your fingertips, the easier it is to file an effective appeal.
Coding Tips 2008
By Emily Hill, PA
Understanding Fluoroscopy Coding
August 8, 2008 -- Basic fluoroscopic guidance codes have been part of CPT since the 1980's. Since that time, codes have been created for more specific clinical circumstances. CPT 2007 renumbered and moved certain codes to a new subsection for Fluoroscopic Guidance codes but did not change the descriptors of the codes. Despite the stability of the service descriptors for fluoroscopic procedures, there remains uncertainly about which specific code to report and when it can be reported.
Inherent or Separately Reported?
Many radiology codes include in the descriptor "supervision and interpretation". These codes require that a formal report be completed and that hard-copy images be obtained. Fluoroscopic guidance is considered an inherent component of many of these services.
For example, fluoroscopy is included in code 72275 (Epidurography, radiological supervision and interpretation) since it is commonly used intermittently during the procedure. In this instance, parenthetical notes in CPT indicate that fluoroscopy (77003) is included in epidurography.
In other instances, the code descriptor specifically states that guidance is part of the procedure. This is the case for the codes for percutaneous lysis of epidural adhesions (62263 and 62264) whose descriptors contain the statement "including radiologic localization".
Parenthetical notes also exist for the fluoroscopic guidance codes. The notes for code 77002 (Fluoroscopic guidance for needle placement [eg, biopsy, aspiration, injection, localization device]) indicate that this service should not be reported separately with any radiographic arthrography except CT and MR arthrography.
In contrast, other parenthetical notes for 77002 refer the coder to surgical codes for procedure and anatomic location. Therefore, both the procedure code and the fluoroscopic guidance code can be reported.
Determining Which Fluoroscopy Code To Report
The appropriate code is determined by the specific procedure performed and the documentation in the medical record. Codes 77002 and 77003 are frequently reported by Pain Medicine physicians. Determining which code to use is necessary to ensure appropriate reimbursement.
Code 77002 (Fluoroscopic guidance for needle placement [eg, biopsy, aspiration, injection, localization device]) is reported for pain medicine injection procedures when guidance is required to perform the needle placement in areas other than the spine. It might be reported in addition to codes 64400-64450, 64505-64530, 64600-64620 or 64630-64680.
In contrast, code 77003 (Fluoroscopic guidance and localization of needle or catheter tip for spine or paraspinous diagnostic or therapeutic injection procedures [epidural, transforaminal epidural, subarachnoid, paravertebral facet joint, paravertebral facet joint nerve, or sacroiliac joint], including neurolytic agent destruction) is used when guidance is required for spinal or paraspinal injections to direct or localize the needle or catheter tip. Therefore when guidance is provided in conjunction with codes 64470-64476 and 64479-64484, code 77003 is reported since these codes are used for spinal procedures.
When reporting code 77003, it is important to recognize that it should be reported once per spinal region. Since the cervical and thoracic regions are two separate regions, code 77003 can be reported once for each region. Likewise, it can be reported twice when guidance is required for procedures performed in the lumbar and sacral regions. It would not be appropriate, however, to report code 77003 more than once when the guidance is at C7-T1, T12-L1, or L5-S1 junctions. In these instances, the 77003 is reported only once.
CPT guidelines indicate you should report the most specific code for the service provided. Therefore when guidance is used in conjunction with pain medicine injection procedures, codes 77002 and 77003 should be reported instead of code 76000 (Fluoroscopy (separate procedure), up to one hour physician time) as they more accurately describe the service rendered.
Distinguishing Fluoroscopy Codes from Other Services
Code 72275 (Epidurography, radiological supervision and interpretation) describes a diagnostic epidurogram and requires hard copy images and a formal report. It should not be used to report needle localization for epidural injections which is more specifically described by code 77003. As stated earlier, fluoroscopic guidance is included in epidurography, thus code 77003 should not be reported separately when a diagnostic epidurogram is provided.
Epidurography does not include the placement of the needle or injection of the contrast. These services are reported in addition to code 72275 using the appropriate injection code (62280-62282, 62310-62319, or 64479-64484).
Likewise, code 73542 (Radiological examination, sacroiliac joint arthrography, radiological supervision and interpretation) also requires image documentation and a formal report and does not include the actual injection. The injection is separately reported using code 27096 (Injection procedure for sacroiliac joint, arthrography and/or anesthetic/steroid). Code 27096 is only reported if imaging guidance is utilized for the injection procedure. Injections without imaging guidance are reported using code 20610 (Arthrocentesis, aspiration and/or injection; major joint or bursa).
When the injection is performed under fluoroscopic guidance but hard copy images and a formal interpretation and report are not provided as required by code 73542, then code 77003 should be reported. Fluoroscopic guidance (77003) should never be reported in addition to code 73542 since it is an inherent component of the arthrography.
Although there may seem to be a number of options and coding combinations, CPT instructions provide specific direction for reporting guidance services with other procedures. Being familiar with these instructions and the appropriate code combinations helps ensure appropriate reimbursement and protects against audit liability.
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