Coding For Correct Payer Adjudication

Transcription

1 Coding For Correct Payer Adjudication Once and Done Kenneth D. Beckman, MD, MBA, CPE, CPC VP/Chief Medical Officer Assurant Health

2 Providers belong to multiple networks New partner has not completed network paperwork by date of service Some providers have different network status depending on: Physical address Network Status In Versus Out of Network TIN number registered with network

3 Network Status In Versus Out of Network Outpatient facility status Physician-owned or Joint Ventures Free-standing Ambulatory Surgical Centers, imaging centers, endoscopy centers Although the facility may have in-network hospital and in-network physician ownership, do not assume the facility is innetwork

4 Network Status Exceptions Exceptions by State and Federal mandates Emergency - regulatory Exceptions by common sense Non-emergency follow-up of emergency services Non-par providers at par facilities: ER, pathology, anesthesiology, radiology, surgical assistants Exceptions by contract Network adequacy Sub-specialists Distance from insured s policy address

5 Contract Denials Some Things You May Not Know Not much of an issue in Large Group business Small Group and Individual Medical may have exclusions that providers do not expect Short Term Medical plans Limited benefit plans

6 Contract Denials Pre-Existing Conditions Still exist for adults in Individual Medical plans (until PPACA fully implemented) May exist in certain circumstances in Group plans (no prior coverage, late additions) Exist for all ages in Short Term Medical plans and Indemnity-type plans Definition varies by State and type of plan LISTEN when you call to pre-certify a service

7 Contract Denials Continuity of Coverage Applicable in Group-to-Group transitions May NOT be currently applicable transitioning from Group to Individual or Short Term Medical plan varies by State of Issue However transition from Individual Medical to Group is usually considered Creditable Coverage.

8 Contract Denials State of Issue All states have mandates that apply to ERISAexempt plans including Individual Medical However, some Individual Medical plans are issued through a situs state that differs from the state of residence and therefore statespecific mandates may or may not apply. Watch for Individual Medical plans referred to as Association plans

9 Contract Denials Certificate Exclusions General exclusions Cosmetic, Experimental/Investigational Specific exclusions Maternity, Behavioral Health, Dental Very specific exclusions Genetic screening, hazardous activities, breast reduction, cranial helmets, etc.

10 Contract Denials Currently allowed in some states in Individual Medical plans: Special Exception Riders (SERs) allows an insurer to accept an applicant who would otherwise be denied coverage. Condition Specific Deductibles (CSDs) Allows an insurer to accept an applicant who would otherwise be declined coverage.

11 Contract Denials Limited Benefit Plans Currently exempt from PPACA regulations May (or may not) continue to exist after full implementation on state-by-state basis May have fixed indemnity benefits, per diems, annual maximums, fee schedules, etc.

12 Claims Software Denials Assistant Surgeon claims Medicare vs. Commercial payers ACS tables SOMETIMES Responsibility of facility Proprietary software Partial approvals Multiple assistants

13 Claims Software Denials Lost Modifiers Be aware that second and subsequent modifiers may be lost: Conversion of paper to electronic claims by intermediary Transmission of electronic claims Limitations of payers internal systems

14 Claims Software Denials Base and Add-on codes Paper bill issue 6 lines per CMS-1500 May also be incorrect submission issue Add-on without base Multiple units of base instead of add-on

15 Claims Software Denials Automated lab interpretations Area of Controversy Pathologists charging per lab study for services not specific to individual patient or individual test Quality oversight Lab oversight Originated with Medicare A vs. B issues

16 Claims Software Denials Phlebotomy fees Some software programs deny phlebotomy when performed by same provider as laboratory analysis If office performs blood draw and reference lab performs tests then covered Claim problems arise with TIN and NPI issues in large practice settings that have separate lab with same ownership

17 Claims Software Denials Handling/conveyance fees ( ) On-call services ( ) Office hour charges ( ) Special reports (99080)

18 Correct Claim Submission Incorrect Claim Adjudication Although the provider submitted correctly and payer processed what was received correctly, errors may occur in the transaction process Most paper claims are converted to electronic claims by intermediary Many PPOs re-price claims before sending them to the payer

19 Bundling Laboratory Panels Routine vital signs (pulse oximetry) E+M codes Preventive service + E/M service

20 Bundling Surgical procedures Bone marrow aspiration and biopsy aspiration ONLY biopsy Separate Procedure Some of the procedures or services listed in the CPT code book that are commonly carried out as an integral component of a total service or procedure have been identified by the inclusion of the term separate procedure. The codes designated as separate procedure should not be reported in addition to the code for the total procedure or service of which it is considered an integral component.

21 Box 21 -> 24E Diagnosis Pointer Very common problem Providers list all diagnoses from Box 21 in Box 24 for every claim line, usually chronologically (1234) Many payers process each claim line by the FIRST diagnosis code Results in denials for mismatched ICD - CPT Mastitis IUD insertion Results in lower claim adjudication if certificate has different benefit levels for different services (eg medical vs. mental health)

22 Box 21 -> 24E Diagnosis Pointer Example Diagnosis 1 = V70.0 General Medical Exam Diagnosis 2 = Wheezing Claim line 1 = office visit Claim line 2 = chest x-ray 2 views If both claims lines show diagnosis pointers as 1,2, some claims systems will deny the chest x-ray on the basis that it is not indicated as part of a routine general medical examination. Claim line 2 should not include diagnosis 1

23 Modifier Mania Modifiers that affect Amount of Payment 22 increased procedural services 26 professional component 50 bilateral procedure 52 reduced services 53 discontinued procedure 62 multiple surgeons 80, 81, 82, AS assistant surgeons Anesthesia status modifiers (P1-P6)

24 Modifier Mania Modifiers that affect Eligibility for Payment 24 unrelated E/M service during post-op period 25 significant separately identifiable E/M service 51 multiple procedures 57 decision for surgery 58 staged or related procedure 59 distinct procedural service 76, 77, 78, 79 unrelated procedure/ unplanned return to OR 91 repeat lab test

25 Modifier Mania Modifiers that specify location RT/LT: Right or left E1-4: Eyelid FA, F1-9: fingers TA, T1-9: toes LC, LD, RC: coronary arteries

26 Modifier Mania General rules of order Pricing modifiers first Payment modifiers next Location modifiers last Special circumstances Global surgery: report first Multiple price modifiers: report AS/80/81/82 first

27 Modifier Mania Wrong use of modifiers 26 modifier on code that has no technical component Surgeons not on the same page One bills with 62 modifier, other bills with no modifier One bills with 62 modifier, other bills with 80 modifier

28 Modifier 50 What is the correct way to submit a bilateral procedure? a. One claim line, modifier 50, charge 150% of base CPT b. First claim line, modifier LT, Second claim line, modifier RT, charge 100% of base CPT on each line c. First claim line, modifier LT, Second claim line, modifiers 51 and RT, charge 100% of base CPT on each line d. First claim line, modifier LT, Second claim line, modifiers 51 and RT, charge 100% of base CPT on first line and 50% of base CPT on second line e. First claim line, modifier LT, Second claim line, modifier RT, charge 75% of base CPT on each line

29 Just What is a Unit? Parenteral drug unit limits Units incorrectly calculated mostly Rx Incorrect units in 24G Common problem on parenteral drugs J1020 methylprednisolone 20 mg J1030 methylprednisolone 40 mg J1040 methylprednisolone 80 mg J1070 testosterone up to 100 mg J1080 testosterone 1cc, 200 mg

30 These Couples Were Not Meant for Each Other Gender edits Male + TAHBSO Age edits (E/M and/or procedure) Preventive medicine visits age Influenza vaccine age Illogical diagnosis for procedure Mastitis IUD insertion 58300

31 When is a Consultation Not a Consultation? Consultation without Box 17 completed 17. Name of referring provider CPT: A consultation is a type of evaluation and management service provided at the request of another physician or appropriate source to either recommend care for a specific condition or problem or to determine whether to accept responsibility... Medicare and Consultations Some software will reject codes if Box 17 is not completed

32 Laboratory Claim Issues NPI/TIN same for OV and lab tests obviously not performed by the provider Box 20 (Outside lab) not completed or shows NO, yet lab reports are from a reference lab Dipstick urinalysis using dipsticks with parameters not under (creatinine)

33 Medicare Codes on Commercial Claims CMS has developed specific HCPCS codes to provide coverage for preventive care services where the office visit is not a benefit G0101 cervical cancer screening G0102 digital rectal exam Q0091 obtain Pap smear

34 Medicare Codes on Commercial Claims ACOG: Non-Medicare Payers: Code Q0091 should not be reported to private payers for pap smear collection. The collection of a pap smear is included in the E/M or preventive medicine service. Some private payers do reimburse for the Q0091 code. In such cases, ACOG strongly recommends obtaining the guidelines for that specific policy in writing.

35 Medicare Codes on Medicare Claims ACOG: Q0091 is a code developed by Medicare for services provided to Medicare patients. Medicare does not reimburse for preventive services, such as those reported with CPT-4 codes Medicare allows payment of code Q0091 as an exception to its general rule. Providers should report code Q0091 to Medicare for the collection of screening pap smears for Medicare patients. However, collection of a diagnostic pap smear for a Medicare patient (performed due to illness, disease, or symptoms indicating a medically necessary reason) is included in the physical examination portion of a problem-oriented E/M service and is not reported or reimbursed separately

36 HCPCS Codes In addition to CMS specific codes, some commercial carriers may not accept S-codes (developed by BC/BS Association, Aetna and HIAA to report drugs, supplies or services for which there are no national codes) Including a charge for Informational codes A necessary evil of automated claims

37 Payer Errors Claims software auto-adjudication Vendor issues Payer modification issues Processor instruction issues Errors are system wide Processor error To err is human Insurer clinician incorrect determinations

38 GIGO A simple rule of life: if it comes in screwed up, the odds are reasonable that we will screw it up more Co-surgeons: one bills with -62 modifier, one bills with no modifier Employed surgical assistant billed with surgeon Tax ID and surgeon PIN Modifier -26 added to professional services only CPT code

39 Colonoscopy Failure to use 33 modifier when pathology found on screening colonoscopy Difference between a screening and a surveillance colonoscopy under Health Reform (see excellent article in March Cutting Edge) Different payment buckets for pre-scope office consultation and pathologist fee

40 Anesthesia Emergency Anesthesia complicated by emergency conditions An emergency is defined as existing when delay in treatment of the patient would have lead to a significant increase in the threat to life or body part. Being submitted for every unplanned C-section even when performed for Failure to Progress

41 Maternity Care OBs billing for urinalysis with each prenatal visit OBs billing an E&M code for the first visit with the diagnosis Absence of Menstruation CPT: Antepartum care includes the initial and subsequent history...routine chemical urinalysis

42 Maternity Care ACOG: The initial OB visit may be reported as an E/M service under certain conditions. Even if the patient has taken a home pregnancy test, the initial visit may still be billed as an E/M service as you will be officially confirming the pregnancy. When coding for the initial ob visit, there are a few things that have to be taken into consideration. First you have to determine if the patient is there for a confirmation of pregnancy or if the pregnancy has already been confirmed. The second thing that needs to be determined is if the OB record has been initiated. Once this has been established you can determine how the visit should be reported.

43 Maternity Care If a patient presents with signs or symptoms of pregnancy or has had a positive home pregnancy test and is there to confirm pregnancy, this visit may be reported with the appropriate level E/M services code. However, if the OB record is initiated at this visit, then the visit becomes part of the global OB package and is not billed separately. If the pregnancy has been confirmed by another physician, you would not bill a confirmation of pregnancy visit. The confirmation of pregnancy visit is typically a minimal visit that may not involve face to face contact with the physician The physician may draw blood and prescribe prenatal vitamins during this initial visit and still report it as a separate E/M service as long as the OB record is not started.

44 Maternity Care Assistant surgeons for C-sections using a global maternity code with the 80 modifier instead of the C-section only code Complications of Pregnancy certificate issues

45 Multiple Gestation Coding ACOG: Both vaginal: or for Twin A and or for Twin B. This method of coding communicates that one global maternity package is being billed along with an additional vaginal delivery (without antepartum care and without postpartum care) One vaginal and one cesarean: or for Twin B and or for Twin A. This communicates that both a cesarean and a vaginal birth were performed. Both cesarean: or only because only one cesarean was performed. If the cesarean was significantly more difficult, a modifier 22 should be added to this code. An operative and special report should also be submitted with the claim that describes the significant additional work.

46 How NOT to Submit an Appeal One major problem we see with appeals is that the individual who coded the original claim is not handling the appeal. Providers provide Coders code Billers bill Appealers appeal The larger the provider organization, the more commonly these roles are separated.

47 How NOT to Submit an Appeal Don t read and understand the reason for the denial Argue medical necessity of the services when that was not the reason for denial Assert service was pre-authorized when you have not listened to the call

48 How NOT to Submit an Appeal Appeal every denial (at least twice) Even 1 information codes Don t wait a reasonable time (typically 30 days) before resubmitting a claim or resubmitting an appeal One of the most common EOB messages used is denial of submission as a duplicate claim

49 How NOT to Submit an Appeal Use form letters Quote non-applicable regulations Threaten Submit altered medical records

50 The Bottom Line Everyone wins with correct claims submission and correct claims adjudication Auto-adjudication cuts payer s overhead Appeals increase overhead for both payers and providers

51 Observations No statistics to support this, but my sense is that 95% of the appeals that I uphold were not submitted by individuals with CPC after their name. Two-fold problem Providers do not hire CPCs to code claims Even if the CPC coded the original claim, the CPCs are not handling the appeals

52 Observations Please remember that in my capacity, I see only the problems. Over 90% of claims submitted are autoadjudicated and never are touched by human hands.

53 Thank you for your time. I will be happy to answer any questions in whatever time we have left. Kenneth D. Beckman, MD, MBA, CPE, CPC Chief Medical Officer, Assurant Health ken.beckman@assurant.com