Adjust or not to adjust an entire transaction?

Transcription

1 Adjust or not to adjust an entire transaction? Adjustments reduce the ability to collect Adjustments reduce your profit Adjustments can create a loss Consequently, before keying an adjustment, we should dig deeper and fully understand the who, what, why, where, and when of the transaction to be adjusted 1

2 Common denials send the message that we cannot get paid and we cannot bill the patient Bundling Not medically necessary Not covered No prior authorization Timely filing Duplicate So what do we do? Adjust? Bundling is usually the most common denial E/M Minor surgical procedures Major surgical procedures X-rays Labs 2

3 Surgeries have global periods Become familiar with the rules that apply to global pricing as they apply to all surgical procedures -- including minor surgeries performed in the physician's office or in an hospital department Charges that occur within a global period of a procedure will be considered bundled or included in the actual surgery How do I unbundle: Know global periods Available on your Medicare website 3

4 Can I unbundle? How do I unbundle? Understand National Correct Coding Initiative (CCI) edits The purpose of the NCCI edits is to prevent improper payment when incorrect code combinations are reported. The NCCI contains two tables of edits. The Column One/Column Two Correct Coding Edits table and the Mutually Exclusive Edits table include code pairs that should not be reported together for a number of reasons explained in the Coding Policy Manual. Coding with Modifiers by Deborah Grider Published by the American Medical Association 4

5 Post-op visits are considered included in the fee that t the surgeon was paid for the actual surgery or the global fee of the surgery What if something develops with the patient that is totally unrelated to their global surgery? We have to be able to communicate this with the payor We communicate with modifiers We do not adjust! Mrs. Sikes has her gallbladder removed on g The global period for this procedure would end on The patient returns on for their 6 week check-up. Her incision is doing well, but she complains of strep throat symptoms. The surgeon documents a history, exam, and medical decision making and wants to bill for a E/M level 3. Can he? 5

6 The payor would deny this E/M since this visit is within the surgical global period Add a 24 modifier to the E/M and a diagnosis code of strep throat The 24 means that this visit was unrelated to the surgery (The diagnosis code change alone will not get the claim paid) The key to avoid the denial is to place the 24 modifier with the E/M before it goes to the insurance company If you receive a denial for this E/M, adjustments can and do occur Does your billing system prompt you when today s charge to be keyed is within a global period.? Do we receive a warning that this may be bundled? If so, we need to verify up front - to save us time and effort on the back end with denials and back-end work 6

7 Does your billing system prompt you when today s charge to be keyed is within a global period? Do you receive a warning that this may be bundled? Verify the nature of the visit prior to keying the charge This saves us time and effort on the back end with denials and back-end work The 24 modifier is only for use on E/Ms 7

8 What happens if the patient has to go back to surgery by the same physician within a global period? Whether additional surgery is planned, unplanned, or unrelated, modifiers again will tell the payor what the circumstances are Don t adjust because the payor tells you to! Modifier 58 staged or planned surgery by the same physician during a postoperative period Modifier 78 Unplanned return to the operating room by the same physician for a related procedure during a post-op period Modifier 79 Unrelated procedure or service by the same physician during the post-op period 8

9 Research patient account to identify the CPT that your recent denial is bundling against may have to go back a full 90 days in the patient record Keep in mind - the charge that is causing the bundling edit will be a charge by the same physician or same specialty Sometimes a procedure is done the same day as an E/M The physician can bill for both and get paid for both, but the documentation needs to justify both One rule (of many)- if the patient is on the appointment book schedule to come today for the procedure, then an E/M is not usually billable.unless 9

10 But if patient comes to the clinic with knee pain and. Doctor documents a history and exam, discusses several treatment options The patient and doc decide that the patient would benefit from receiving an injection into the joint (20610) Decision is made at the visit, then the physician should be paid for both the E/M and the A 25 modifier must be appended on the E/M Here is an example of multiple unrelated procedures same day Patient comes in with knee pain, and abscess, and a skin lesion Codes billed are 20610, 10060, and Insurance pays 20610, denies the other 2 as included Don t adjust them do your research! First, determine the location of all three 10

11 20610 performed on the knee I&D abscess on the finger skin lesion on the face Three separate areas all unrelated to each other Use the 59 modifier on the and the to tell the payor that these were separate procedures Skin lesion removals are commonly done in multiples during a visit The 59 modifier would need to be used on any of the 2 nd or 3 rd skin lesions removed to notify the payor that these were in separate areas, i.e. hand, foot, neck 11

12 Decision for surgery same day as surgery Surgeon sees a patient today in the ER who has a compound fracture that will require immediate surgery the surgeon explains risks, what procedure he will do, etc and the decision for surgery is made just prior to doing the surgery Insurance will deny this visit as being provided during the global period of the surgery Don t adjust this visit off! If surgery has a 90 day global period, attach modifier 57 to the E/M If surgery has a 10 day global period, attached modifier 25 to the E/M 12

13 Not medically necessary denials The physician may order tests that he feels are necessary to diagnose the condition Rarely will he order something that is not medically necessary! If we receive a denial for CO50 -not medically necessary, then these usually occur because we failed to include all of the necessary diagnoses on the claim Before you adjust, search the chart documentation to see if the reason for the ordered test was documented, but not coded on the fee ticket Check with the physician or nurse if unsure It should be a rare occasion that a charge is adjusted off for not being medically necessary 13

14 Denials for service not covered This is different from not medically necessary We don t automatically adjust these off! Cosmetic procedures are never covered Weight loss plans are never covered If we bill these services to the insurance company, and receive the denial that the service is not covered, then we must bill the patient for these services not adjust them off Medicare also has non-covered services. Denials PR-49 and PR-96 - These ANSI denial code that begins with PR means patient responsibility Medicare is telling us to Bill the Patient! t! So bill the patient - Do not adjust! 14

15 No prior authorization denials Surgical procedure Visits Hospital stay X-rays Your hospital is a resource for info. They may have obtained a PA# and then we can refile our claim with this number in the appropriate field Some payors do retro-auths. See if they will allow us to provide additional information sometimes this might require a letter from the physician to explain extenuating circumstances 15

16 Timely filing denials Do not Adjust until research is done Payors have different timely filing deadlines Aetna 90 days BCBS 180 days Medicare one year from DOS United Health Care 90 days Be familiar with the deadlines of each of your major payors New claims for today s visits are not the problem Corrected claims are usually the culprit Denial is received and we make a change CPT, DX, DOS, ID# A new claim is submitted with the correct information, but it is now beyond the payors filing deadline What do we do? 16

17 Attach a copy of the denial to the claim and mail in hard copy proving that t the claim was originally filed timely, but denied Write on the new corrected claim the previous claim number that was assigned by the payor Also indicate on the claim that this is Corrected Or Corrected Claim SYTG This will refer the payor to their system s previous assigned claim number Sometimes patient s do not give us the correct insurance information We file a claim to BCBS BCBS denies for coverage termed We contact patient to find out correct policy info. Now they have Aetna, so we correct our system demographics and refile This claim doesn t hit Aetna s system until 90 days after the DOS denied for timely filing What can we do now? 17

18 Payors are aware that this situation does occur If we can provide a copy of our electronic claims acknowledgement showing where we initially filed to the wrong payor, BCBS, in a timely manner, the payor will process our claim MVAs and WC also contribute to some of the timely filing denials that we receive We may see a patient a few times as a result of a MVA and file to their auto insurance carrier, but then they have maxed out their benefit When filing now to their group insurance, we should include a copy of the dated letter from the MVA insurance to prevent any timely filing deadlines 18

19 Very rarely should there ever be an adjustment for Timely Filing Our systems drops claims daily: As long as we can prove that we did file it initially by using an electronic claims acknowledgement report we will be able to receive payment every time Duplicate denials A charge is keyed twice with same DOS A charge is billed as a qty 2 - bilateral A charge is processed twice - denied as duplicate but we have still not been paid Need to call the payor Each duplicate denial should be researched fully 19

20 Keying error? Duplicate hospital visits billed on same DOS 2-08 Was this a keying error? Check to see if there was a visit billed on 2-07 or 2-09 Bilateral? Did we bill two of something and not use RT/LT or the 50 modifier for bilateral procedure? Payment already received? If so, discard denial If not, the payor should be contacted Conclusion: Don t adjust just because the payor says so We are obligated to adjust contractual obligations such as amounts over the allowable for the insurance companies that we have agreements with Medicare, Medicaid, BCBS, PPOs, etc. However, when the insurance company disallows the entire charge for one of the reasons that we reviewed here today, have a plan 20

21 Don t adjust without getting g to the root of the problem maybe as much as 89 days ago! Understand global days and the correct use of modifiers to unbundle appropriately Understand that by doing an adjustment, our physicians i will never be paid for performing a service that they provided MORE CASH! LESS ADJUSTMENTS! 21