Here 11 coding and billing tips for three ambulatory surgery center specialties.
ENT
1. Know 2015 CPT code updates. A number of Current Procedural Terminology code set changes for 2015 are expected to impact otolaryngology, according to the American Academy of Otolaryngology – Head and Neck Surgery.
Changes include:
• 43180, a new code for the reporting of Endoscopic Zenker's Diverticulum
• Deletion of Eustachian tube codes 69400, 69401 and 69405
The American Medical Association RVS Update Committee also reviewed the following codes:
• 92541
• 92542
• 92543
• 92544
• 92545
• 10021
• 30903
• 30905
• 31295
• 31296
• 31297
• 41530
• 30300
• 30906
• 40804
• 42809
• 69200
• 69220
• 92511
Each of these codes could be subject to changes in reimbursement. See the American Academy of Otolaryngology – Head and Neck Surgery report for the full code descriptions.
2. Track external benchmarks. External benchmarking can help healthcare leaders understand if they are capturing as much revenue as efficiently as possible. Here are 10 statistics on ENT revenue per case in ambulatory surgery centers, according to VMG Health's 2012 Intellimarker Ambulatory Surgical Center Financial & Operational Benchmarking Study.
West
• Gross charges per case: $8,426
• Net revenue per case: $1,740
Southwest
• Gross charges per case: $8,673
• Net revenue per case: $2,071
Midwest
• Gross charges per case: $7,710
• Net revenue per case: $2,172
Southeast
• Gross charges per case: $6,537
• Net revenue per case: $1,369
Northeast
• Gross charges per case: $7,494
• Net revenue per case: $2,009
GI/endoscopy
1. Prepare for impending coding changes. Approximately 25 percent of the 2014 CPT code updates affected gastroenterology, due to the review of upper GI/endoscopy codes. In 2014 some of the biggest changes, according to a Becker's ASC Review report, included additions to cover esophagoscopy, esophagogastroduodenoscopy, endoscopic retrograde cholangiopancreatography and image-guided fluid collection drainage by catheter. The changes were reflected in the following codes:
• Codes 43191-43918
• Codes 43211-43214
• Code 43229
• Code 43233
• Codes 43253-43254
• Code 43266
• Codes 43270
• Codes 43274-43278
• Codes 49405-49407
This year, lower GI/endoscopy codes, including colonoscopy, are up for review. A significant number of changes reflected in the 2015 CPT code set are expected to impact GI.
2. Avoid common mistakes. Here are four common GI/endoscopy coding and billing mistakes to understand and avoid, according to a recent Becker's ASC Review article.
• Modifiers. One of the most common GI/endoscopy coding mistakes is caused by confusion between modifiers -51 and -59.
• Upcoding. Upcoding can occur when a follow-up visit with an established patient is coded at a level corresponding with a new patient office visit.
• Patient information collection. Failure to collect patient insurance information and verify benefits can lead to denied claims.
• Documentation. Payers are demanding to see patient medical records and physicians may not be prepared. Clean, accurate documentation is essential for avoiding coding errors and denials.
3. Prepare for the ICD-10 transition. The ICD-10 transition has been delayed until Oct. 1, 2015, but GI field stakeholders must still prepare. Here are three considerations for gastroenterologists on the impending adoption of ICD-10, according to a Becker's ASC Review article.
• Increased specificity. The largest difference between ICD-9 and ICD-10 is the sheer number of codes. The jump in the number of codes is designed to allow for greater specificity. For example, the ICD-9 code for Internal Hemorrhoids without Mention of Complication is 455.0, but in ICD-10 the codes to describe this condition will expand to include:
• K64.0: 1st Degree Hemorrhoids
• K64.1: 2nd Degree Hemorrhoids
• K64.2: 3rd Degree Hemorrhoids
• K64.3: 4th Degree Hemorrhoids
• K64.4: Residual Hemorrhoidal Skin Tags
• K64.5: Perianal Venous Thrombosis
• K64.8: Other Hemorrhoids
• K64.9: Unspecified Hemorrhoids
• Budget considerations. Expenses to factor into ICD-10 preparation include new EHR and practice management software, software upgrades, staff training and physician training.
• Physician preparation. Engage gastroenterologists in the preparation process. For example, work with physicians to identify the top ICD-9 codes and create a document of corresponding ICD-10 codes.
OB/GYN
1. Know coding updates. In 2014, the American Medical Association released 335 changes to its Current Procedural Terminology code set. Amongst these changes were code additions. "Category III code 0336T is a new code for laparoscopy, surgical, ablation of uterine fibroid(s), including intraoperative ultrasound guidance and monitoring, radiofrequency which has been added to the Medicare ASC List for 2014 with an average Medicare payment of $4,671," said Stephanie Ellis, RN, CPC, president of Ellis Medical Consulting, in a Becker's ASC Review article.
Keeping abreast of coding updates ensures that claims will not be unnecessarily denied and maximizes reimbursement. The CPT changes for 2015 will go into effect Jan. 1, 2015.
2. Avoid common causes of denials. Here are the top five unexpected denied procedures by CPT code for OB/GYN in March 2014, according to a Physician's Practice report.
• 99000: Specimen handling office-lab
• 99213: Outpatient doctor visit, level 3
• 81002: Urinalysis non-automated without scope
• 36415: Routine blood capture
• 99214: Outpatient doctor visit, level 4
The top five reason codes for these denials are as follows:
• 97: Benefit for service is already included in the payment for another service/procedure already adjudicated
• 18: Duplicate claim/service
• 16: Claim lacks information or has errors
• 234: Procedure is not paid separately.
• 96: Non-covered charge(s)
3. Prepare for ICD-10. Here are six tips for the ICD-10 transition in the OB/GYN field, according to Kareo.
• Document specific trimesters. For example, ICD-10-CM code O09.01 is equated with supervision of pregnancy with history of infertility, first trimester.
• Take care when documenting an annual gynecological exam. The code for an annual GYN exam is included in ICD-10-CM chapter 21, not chapter 15. Code Z01.4 denotes a routine GYN exam.
• Document cause of pelvic pain. If cause of pelvic pain is know, OB/GYN physicians should document this information.
• Document carefully in regards to migraines. Specify a patient has menstrual migraines when she complains of chronic migraines related to menstrual cramps.
• Document reason for fetus visibility scans. When documenting fetus visibility scans, specify if it is a routine screening or if there are any signs indicating a possible miscarriage.
• Specify if patient's age complicates pregnancy. If a patient is older than 35 years of age, indicate whether or not age may affect delivery.
Orthopedics
1. Keep abreast of coding updates. The American Medical Association rolls out a number of changes to its Current Procedural Terminology code set each year. Changes in 2014, according to Becker's ASC Review report, included:
Codes related to removal of foreign bodies, prosthesis removal and knee procedures. The new codes include 23333 to 23335, 27415 and 27524.
"Code 27415 for open osteochondral allograft, knee, open, is an existing CPT code, which is newly-added to the Medicare ASC list for 2014 with an average Medicare payment of $2,242," said Stephanie Ellis, RN, CPC, president of Ellis Medical Consulting, in the report.
There were also changes made to arthroscopic knee synovectomy codes 29875 and 29876. "Medicare no longer allows either of these codes to be billed when any other arthroscopic procedure is performed on the same knee in the same surgical case, due to strict enforcement of the CCI edits," said Ms. Ellis. Strict CCI edit enforcement has also extended to include codes involving some arthroscopic shoulder procedures.
The AMA is expected to announce the 2015 CPT code change, which will go into effect Jan. 1, 2015.
2. Track and avoid common denials. Here are the five most common unexpected orthopedics claim denials that occurred from Oct. 19, 2013 to Jan. 16, 2014, according to RemitDATA.
• CPT code 99213: Outpatient doctor visit, level 3
• CPT code 20610: Aspiration and/or injections; major joint or bursa
• CPT code 99203: Outpatient doctor visit, new patient, level 3
• CPT code 99214: Outpatient doctor visit, level 4
• CPT code 97110: Therapeutic exercises
The top reason codes for these unexpected denials include:
• 45: Charge exceeds fee schedule
• 23: Prior payer(s) adjudication affected this payment and/or adjustment
• 18: Duplicate claim/service
• 59: Processed based on multiple or concurrent procedure rules
• 223: Mandated adjustment code when other code not applicable
Track the root causes of common denials and put processes in place to avoid these denials in the future. Three key actions to take to avoid denials, according to a Health Information Services report, include:
• Diligent insurance verification
• Accurate patient information collection
• Selecting an automated billing service
3. Understand upcoming ICD-10 changes. ICD-10 affects every specialty in medicine, including orthopedics. Here are five ICDA-10 changes in orthopedics coding to expect, according to Kareo.
• Site specificity. Many orthopedics diagnoses will require documentation of specific regions of the body. For example, a diagnosis of spondylosis or spinal stenosis will require physicians to indicate the specific region of the spine.
• Laterality. ICD-9 codes did not capture laterality, but in the ICD-10 code set physicians must document left, right or bilateral for a number of conditions, such as joint disorders and fractures.
• Type of encounter. Physicians will need to document with a level of specificity high enough that coders can understand if the encounter was initial, subsequent or sequela.
• Combination codes. There are not many orthopedic combination codes in ICD-10, but they do exist. For example, M54.4 indicates lumbago with sciatica.
• Place of occurrence codes. ICD-10's largest demand is for more specificity. Payers will need to see documentation of where an injury occurred, for example code Y92.250 indicates an injury took place in an art gallery.
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