Here are five ways to improve coding at your ambulatory surgery center, according to Daria Semanyshyn of Advanced Medical Practice Management.
1. Understand the importance of detailed operative notes. According to Ms. Semanyshyn, the most important factor in properly coding a procedure is a detailed op note. "Let's take colonoscopies, for example: Detailed notes should include the method of removal of the polyps and the sections of the colon from which they are removed," she says. "This will determine what code we should use." In a case where the physician performed two methods of removal in two separate locations of the colon, a second procedure may be billed. "Lack of detailed documentation will result of potential income that your center is entitled to."
Ms. Semanyshyn says descriptive keywords, measurements and listed implants are factor into proper coding of CPT and diagnosis codes. She says orthopedic operative notes should include narrative phrases such as "with or without," "limited or extensive" and "partial or complete."
2. Hire experienced coders. Your ASC will benefit from hiring experienced coders who understand the subtle differences between certain codes and modifiers. "[An experienced coder should] understand what is considered bundled or inclusive to the primary procedure code and what is separately billable," Ms. Semanyshyn says.
3. Improve the dialogue between physician and coder. Since proper documentation is essential for accurate coding, the ASC should facilitate an open dialogue between the biller and the physician, Ms. Semanyshyn says. "Very often, we send back op notes that are missing details, and we ask the pertinent questions that affect what CPT should be billed," she says. "In doing this, doctors begin to understand the level of detail the billing department needs."
4. Hire an outside consultant to review the process. "This is a small investment that can produce big returns," Ms. Semanyshyn says. Consultants can objectively determine where coding issues exist and give constructive suggestions for improvement. If your ASC is unaware of recent or upcoming coding changes that could affect your compliance or reimbursement, a good consultant should be able to keep you up-to-date.
5. Hear about coding changes as they happen. Don't wait until you've been coding claims inaccurately for months to implement coding changes at your facility. Ms. Semanyshyn says her company uses Medicare to stay up-to-date on coding changes. "They usually set the standard for the industry," she says. She also recommends ASCs subscribe to monthly coding newsletters and become members of various medical societies and associations by specialty. "Specialty websites are useful, as they provide important information and their blogs allow for an exchange of ideas, issues and solutions to billing," she says.
The information provided should be utilized for educational purposes only. Please consult with your billing and coding expert. Facilities are ultimately responsible for verifying the reporting policies of individual commercial and MAC/FI carriers prior to claim submissions.
1. Understand the importance of detailed operative notes. According to Ms. Semanyshyn, the most important factor in properly coding a procedure is a detailed op note. "Let's take colonoscopies, for example: Detailed notes should include the method of removal of the polyps and the sections of the colon from which they are removed," she says. "This will determine what code we should use." In a case where the physician performed two methods of removal in two separate locations of the colon, a second procedure may be billed. "Lack of detailed documentation will result of potential income that your center is entitled to."
Ms. Semanyshyn says descriptive keywords, measurements and listed implants are factor into proper coding of CPT and diagnosis codes. She says orthopedic operative notes should include narrative phrases such as "with or without," "limited or extensive" and "partial or complete."
2. Hire experienced coders. Your ASC will benefit from hiring experienced coders who understand the subtle differences between certain codes and modifiers. "[An experienced coder should] understand what is considered bundled or inclusive to the primary procedure code and what is separately billable," Ms. Semanyshyn says.
3. Improve the dialogue between physician and coder. Since proper documentation is essential for accurate coding, the ASC should facilitate an open dialogue between the biller and the physician, Ms. Semanyshyn says. "Very often, we send back op notes that are missing details, and we ask the pertinent questions that affect what CPT should be billed," she says. "In doing this, doctors begin to understand the level of detail the billing department needs."
4. Hire an outside consultant to review the process. "This is a small investment that can produce big returns," Ms. Semanyshyn says. Consultants can objectively determine where coding issues exist and give constructive suggestions for improvement. If your ASC is unaware of recent or upcoming coding changes that could affect your compliance or reimbursement, a good consultant should be able to keep you up-to-date.
5. Hear about coding changes as they happen. Don't wait until you've been coding claims inaccurately for months to implement coding changes at your facility. Ms. Semanyshyn says her company uses Medicare to stay up-to-date on coding changes. "They usually set the standard for the industry," she says. She also recommends ASCs subscribe to monthly coding newsletters and become members of various medical societies and associations by specialty. "Specialty websites are useful, as they provide important information and their blogs allow for an exchange of ideas, issues and solutions to billing," she says.
The information provided should be utilized for educational purposes only. Please consult with your billing and coding expert. Facilities are ultimately responsible for verifying the reporting policies of individual commercial and MAC/FI carriers prior to claim submissions.