Here are eight suggestions from five industry experts on ways to improve your ambulatory surgery center's coding process and overall revenue cycle.
1. Obtain correct physician documentation. Obtain full documentation for spine procedures, operative notes, anesthesia and medication list before you begin coding.
"You have to make sure all is in order before starting to code," said National Medical Billing Service's Senior Vice President Angela Talton. "There are several challenges, especially when we have more than one procedure. We have to ensure we are assigning the level of specificity for any spine procedure and the correct modifiers. Claims can be denied because modifiers are not affixed to the second tertiary procedure. That can be very costly and time consuming from a revenue cycle point of view."
This documentation will become even more specific after the transition to ICD-10 in October 2014. Surgery centers can provide physician education courses to make sure they are ready for the transition.
"Physician education is going to be critical during the upcoming days, weeks and months leading up to ICD-10 conversion," she said. "Physicians need to be made very aware of how they are noting procedures. They need to be very specific and aware of how they are wording their reports to avoid ambiguity in their operative findings. I suspect there will be physician queries when the operative notes are not clear, so if there is an opportunity for physician education, start now and continue through implementation. Otherwise, there is a huge drop in reimbursement because of that."
2. Stay up-to-date with payor policies. Payors can change certain policies yearly, said Lolita Jones, RHIA, CCS, a consultant specializing in ASC and hospital outpatient coding, billing, reimbursement and operations. Coders should be diligent to check the payor websites for any coverage determination or medical necessity policy changes.
"Your center can take a hit if the diagnosis that would justify a procedure isn't there for the particular payor," she said.
While patients may still need a procedure to be performed even if it will no longer fall under the purview of a payor's coverage, by staying educated with policies the coders are avoiding the shock of a denied claim.
"At least you'll know on the front end that you may be in trouble," Ms. Jones said. "You may be able to go to the physician and see if there is an aspect of the diagnosis they forgot to include. Even perfect coding could get dinged by a medical necessity problem."
3. Learn from denials. Bill Gilbert is the vice president of marketing for AdvantEdge Healthcare Solutions. He suggests looking at all denials as they come in and developing a feedback loop for coders and physicians to understand what went wrong.
"If a denial comes in because the code was in the wrong sequence or the wrong modifier was in place, you can't appeal the denial, but you can make sure not to make the same mistake again," he said.
Studying denials is as important for high-volume cases as it is for high-dollar cases. In some GI procedures, for example, the lost money for one claim may not be significant, but a pattern of denials can add up.
Communication is always the key to bridging the gap between the coder and the physician.
4. Code spinal median branch blocks together. The AMA published official guidelines around four years ago that said coders should not assign a code for the injection of each median branch when a physician is performing a median branch block, Ms. Jones said. "Two median branches in the spine actually support one facet joint, so if two median branches are blocked with an anesthetic, the official guideline is to code that as a single facet joint injection," she said.
She says in her experience, coders often report an injection code for each median branch. "That's [up-coding], and the AMA recently reiterated its guideline," she said. "Unfortunately, not only are the coders doing that, but physicians who do their own coding in the ASC are doing it as well. They'll say, 'I placed two needles in two different locations,' but the AMA understands that and [still insists that one facet joint injection code is appropriate]."
Coders who submit codes for two injections will be overpaid, and payors will likely not notice the error unless the payor requests the operative report. Centers can run into trouble if their coding processes are audited and mistakes like this are discovered. "Even if they say, 'We didn't know about the guidelines', OIG doesn't care about that," she said.
5. Obtain additional coding certifications. Quality measures will continue to be ramped up for ASCs. Coders and billers should seek additional coding certification to handle the new procedures and regulations, both for healthcare generally and for their specialty.
"It is common to see coders now with two or more certifications, and I believe that will increase," said Tammy Luttenberger, billing and collections manager for Hudson Valley Ambulatory Surgical Center in Middletown, N.Y. "It's important to maintain current credentials and consider adding more to verify our expertise."
Set and meet accuracy standards. The only way to know if your coders are staying accurate and timely is by setting an accuracy target and doing periodic audits to measure the accuracy rate.
Brice Voithofer, the vice president of ASC and anesthesia services for AdvantEdge Healthcare Solutions, suggests coders be asked to maintain at least a 95 percent accuracy rate and says up to 98 percent is reasonable and attainable.
Whenever a new coder joins your center, he or she should be audited more frequently until all parties are confident in the coder's abilities to perform at an expected level.
Accuracy may also be taking a hit if coders are simply entering what the physician has checked off on the charge ticket, rather than actually coding the claim. Coders cannot rely on the ticket, Ms. Jones said. They can validate against the physician notes, but they should be coding as well.
6. Code for add-ons when possible, but don't unbundle. Coders often miss opportunities to include add-on codes, especially with spine surgery. When procedures are performed on one level followed by a subsequent procedure, you can use an add-on code.
"The correct way to code multiple procedures is to code the first procedure and use an add-on for the second," Ms. Talton said. "However, they must be careful not to unbundle or bundle CPT codes because that's an unethical procedure."
Avoid unbundling if there are incidental services in the surgical package reported, which are included within the main procedure. "They should check each procedure code with CPT bundling edits and pay attention to CPT guidelines when they are coding," she said. "Query the physician to make sure the second procedure wasn't included in the main procedure."
7. Learn to properly code nasal sinus surgery. "I find a number of issues with nasal sinus surgery, and the big issue would have to be the coding of the removal of tissues on the maxillary sinus," Ms. Jones said. There are two categories of codes that give the coder the option of reporting sinus surgery with the removal of tissue and without, and frequently coders will assign a code that does not involve tissue removal when the procedure involved tissue removal from the maxillary sinus. This may not be an issue of under- or over-payment, but rather an issue of coding compliance.
Coders may fall down on sinus surgery codes because the frequency of the surgeries has picked up in recent years. "People are living longer, and years ago, sinus wasn't a big deal and there wasn't a lot of surgery," she said. "Now people are coming in with all sorts of sinus troubles, and coders are seeing procedures they probably never saw in the past."
8. Follow the 2010 excision of skin and soft tissue lesions rule. At the beginning of 2010, major coding changes were introduced regarding the excision of skin and soft issue lesions, adding a number of codes for the excision of soft tissue lesions to distinguish from the excision of skin lesions. "A number of coders are still coding for the skin system when it's actually from the musculoskeletal system," Ms. Jones said. "Most payors will pay more for a soft tissue lesion excision than a skin lesion excision." Centers may lose money if their coders have not properly analyzed yearly coding changes or lack the necessary knowledge on anatomy and physiology.
"In this case, it may be a matter of bulking up on their anatomy a little more and looking at some anatomical diagrams," she said. "They should be saying, 'I'm seeing that the lesion was removed all the way down to the subcutaneous tissue, and that takes me to musculoskeletal for coding.'"
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1. Obtain correct physician documentation. Obtain full documentation for spine procedures, operative notes, anesthesia and medication list before you begin coding.
"You have to make sure all is in order before starting to code," said National Medical Billing Service's Senior Vice President Angela Talton. "There are several challenges, especially when we have more than one procedure. We have to ensure we are assigning the level of specificity for any spine procedure and the correct modifiers. Claims can be denied because modifiers are not affixed to the second tertiary procedure. That can be very costly and time consuming from a revenue cycle point of view."
This documentation will become even more specific after the transition to ICD-10 in October 2014. Surgery centers can provide physician education courses to make sure they are ready for the transition.
"Physician education is going to be critical during the upcoming days, weeks and months leading up to ICD-10 conversion," she said. "Physicians need to be made very aware of how they are noting procedures. They need to be very specific and aware of how they are wording their reports to avoid ambiguity in their operative findings. I suspect there will be physician queries when the operative notes are not clear, so if there is an opportunity for physician education, start now and continue through implementation. Otherwise, there is a huge drop in reimbursement because of that."
2. Stay up-to-date with payor policies. Payors can change certain policies yearly, said Lolita Jones, RHIA, CCS, a consultant specializing in ASC and hospital outpatient coding, billing, reimbursement and operations. Coders should be diligent to check the payor websites for any coverage determination or medical necessity policy changes.
"Your center can take a hit if the diagnosis that would justify a procedure isn't there for the particular payor," she said.
While patients may still need a procedure to be performed even if it will no longer fall under the purview of a payor's coverage, by staying educated with policies the coders are avoiding the shock of a denied claim.
"At least you'll know on the front end that you may be in trouble," Ms. Jones said. "You may be able to go to the physician and see if there is an aspect of the diagnosis they forgot to include. Even perfect coding could get dinged by a medical necessity problem."
3. Learn from denials. Bill Gilbert is the vice president of marketing for AdvantEdge Healthcare Solutions. He suggests looking at all denials as they come in and developing a feedback loop for coders and physicians to understand what went wrong.
"If a denial comes in because the code was in the wrong sequence or the wrong modifier was in place, you can't appeal the denial, but you can make sure not to make the same mistake again," he said.
Studying denials is as important for high-volume cases as it is for high-dollar cases. In some GI procedures, for example, the lost money for one claim may not be significant, but a pattern of denials can add up.
Communication is always the key to bridging the gap between the coder and the physician.
4. Code spinal median branch blocks together. The AMA published official guidelines around four years ago that said coders should not assign a code for the injection of each median branch when a physician is performing a median branch block, Ms. Jones said. "Two median branches in the spine actually support one facet joint, so if two median branches are blocked with an anesthetic, the official guideline is to code that as a single facet joint injection," she said.
She says in her experience, coders often report an injection code for each median branch. "That's [up-coding], and the AMA recently reiterated its guideline," she said. "Unfortunately, not only are the coders doing that, but physicians who do their own coding in the ASC are doing it as well. They'll say, 'I placed two needles in two different locations,' but the AMA understands that and [still insists that one facet joint injection code is appropriate]."
Coders who submit codes for two injections will be overpaid, and payors will likely not notice the error unless the payor requests the operative report. Centers can run into trouble if their coding processes are audited and mistakes like this are discovered. "Even if they say, 'We didn't know about the guidelines', OIG doesn't care about that," she said.
5. Obtain additional coding certifications. Quality measures will continue to be ramped up for ASCs. Coders and billers should seek additional coding certification to handle the new procedures and regulations, both for healthcare generally and for their specialty.
"It is common to see coders now with two or more certifications, and I believe that will increase," said Tammy Luttenberger, billing and collections manager for Hudson Valley Ambulatory Surgical Center in Middletown, N.Y. "It's important to maintain current credentials and consider adding more to verify our expertise."
Set and meet accuracy standards. The only way to know if your coders are staying accurate and timely is by setting an accuracy target and doing periodic audits to measure the accuracy rate.
Brice Voithofer, the vice president of ASC and anesthesia services for AdvantEdge Healthcare Solutions, suggests coders be asked to maintain at least a 95 percent accuracy rate and says up to 98 percent is reasonable and attainable.
Whenever a new coder joins your center, he or she should be audited more frequently until all parties are confident in the coder's abilities to perform at an expected level.
Accuracy may also be taking a hit if coders are simply entering what the physician has checked off on the charge ticket, rather than actually coding the claim. Coders cannot rely on the ticket, Ms. Jones said. They can validate against the physician notes, but they should be coding as well.
6. Code for add-ons when possible, but don't unbundle. Coders often miss opportunities to include add-on codes, especially with spine surgery. When procedures are performed on one level followed by a subsequent procedure, you can use an add-on code.
"The correct way to code multiple procedures is to code the first procedure and use an add-on for the second," Ms. Talton said. "However, they must be careful not to unbundle or bundle CPT codes because that's an unethical procedure."
Avoid unbundling if there are incidental services in the surgical package reported, which are included within the main procedure. "They should check each procedure code with CPT bundling edits and pay attention to CPT guidelines when they are coding," she said. "Query the physician to make sure the second procedure wasn't included in the main procedure."
7. Learn to properly code nasal sinus surgery. "I find a number of issues with nasal sinus surgery, and the big issue would have to be the coding of the removal of tissues on the maxillary sinus," Ms. Jones said. There are two categories of codes that give the coder the option of reporting sinus surgery with the removal of tissue and without, and frequently coders will assign a code that does not involve tissue removal when the procedure involved tissue removal from the maxillary sinus. This may not be an issue of under- or over-payment, but rather an issue of coding compliance.
Coders may fall down on sinus surgery codes because the frequency of the surgeries has picked up in recent years. "People are living longer, and years ago, sinus wasn't a big deal and there wasn't a lot of surgery," she said. "Now people are coming in with all sorts of sinus troubles, and coders are seeing procedures they probably never saw in the past."
8. Follow the 2010 excision of skin and soft tissue lesions rule. At the beginning of 2010, major coding changes were introduced regarding the excision of skin and soft issue lesions, adding a number of codes for the excision of soft tissue lesions to distinguish from the excision of skin lesions. "A number of coders are still coding for the skin system when it's actually from the musculoskeletal system," Ms. Jones said. "Most payors will pay more for a soft tissue lesion excision than a skin lesion excision." Centers may lose money if their coders have not properly analyzed yearly coding changes or lack the necessary knowledge on anatomy and physiology.
"In this case, it may be a matter of bulking up on their anatomy a little more and looking at some anatomical diagrams," she said. "They should be saying, 'I'm seeing that the lesion was removed all the way down to the subcutaneous tissue, and that takes me to musculoskeletal for coding.'"
More Articles on Coding and Billing:
Obama Says GOP Differences on Medicare May be "Too Wide" for Grand Bargain
Updated CMS ICD-10 Implementation Guides Now Available
2014 ICD-10 Deadline Here to Stay