ADVANCED CLNC®

Practice-Building Program

Vickie L. Milazzo RN, MSN, JDNEW YORK TIMES BESTSELLING AUTHOR THE PIONEER OF LEGAL NURSE CONSULTING

EDITED BY

institute

institute

Break the Medical Code

When Analyzing Medical-Related

Cases

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BREAK THE MEDICAL CODE WHEN ANALYZING MEDICAL-RELATED CASES

CONTENTS

I. Introduction ........................................................................................................... 1 II. Common Types of Auditing Cases ....................................................................... 4 III. Common Defenses for Insurance Fraud Cases .................................................... 5 IV. The Role of the Certified Legal Nurse ConsultantCM in

Medical Auditing Cases ........................................................................................ 6 V. Interrogatories and Requests for Production ........................................................ 8 VI. Recommended Qualifications for CLNC® Subcontractors for

Expanding Your CLNC® Practice Into the Medical Auditing Field ....................... 11 VII. Resources .......................................................................................................... 12

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BREAK THE MEDICAL CODE WHEN ANALYZING MEDICAL-RELATED CASES

I. INTRODUCTION

A. Expand Your Legal Nurse Consulting Business into Medical

Insurance Auditing

1. Insurance fraud costs are constantly rising. As a Certified Legal Nurse ConsultantCM, you can make a difference in stopping insurance fraud.

2. You already have a great deal of medical knowledge as an RN and

this can make coding and medical billing easier to learn. Many medical billing/coding companies, attorneys, lawyers and insurance companies are actively searching for RNs with coding certification.

B. Obtaining Proper Billing or Coding Information and Certification

1. Accredited schools. a. American Academy of Professional Coders (AAPC)

www.aapc.com 800.626.2633 and 801.236.2200 2480 South 3850 West, Ste B Salt Lake City, UT 84116- 3127

b. American Health Information Management Association (AHIMA) www.ahima.org 800.335.5535 233 N. Michigan Avenue 21st Floor Chicago, IL 60601-5809

2. Relevant sources.

a. Current Procedural Terminology (CPT®). (1) This system was developed by the American Medical

Association (AMA®) as a listing of descriptive terms and identifying codes for reporting medical services and various other professional procedures performed by providers. The purpose of the terminology is to provide a uniform language that will accurately describe medical, surgical and diagnostic services. This coding system will thereby provide an effective means for reliable, nationwide communication among providers, patients and third parties. This system is

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owned by the AMA and all changes, deletions and updates to coding policies are made by them. Essentially, it is numeric shorthand to describe the medical, surgical and diagnostic services that were provided. (a) Modifiers: Modifiers are an extremely important

part of the Procedural Terminology coding system. A modifier is a two-digit number or letter that merely adds additional information to the Procedural Terminology code. It does not change the Procedural Terminology code. When used properly, the addition of the modifier can actually increase reimbursement payment to the provider. (Exhibit A)

b. International classification of diseases (ICD). (1) Originally developed by the World Health

Organization and the International Statistical Institute to study and classify the causes of death listed on death certificates and other medical documents. This ensured all providers would be using the same diagnosis coding system. Therefore, one positive attribute was the diagnoses coding was born, similar to the shorthand Procedure Terminology coding system to simplify and allow accurate medical diagnosis coding. The ICD-10-CM far exceeds its predecessors in the number of concepts and codes provided. The disease classification has been expanded to include health-related conditions and to provide greater specificity at the sixth and seventh characters and are not optional.

(2) They are intended for use in recording the information documented in the clinical record. (Exhibit B)

c. Healthcare Common Procedure Coding System (HCPCS) coding. (1) This supplemental coding book is used for the proper

coding of services, supplies, equipment and drugs. HCPCS codes are made up of 25 alphanumeric characters, starting with a letter that represents a category of similar codes, followed by four numbers. These tabular list codes in alphanumeric order begin with A. The code description identifies like items or services in each tabular list, but do not identify a particular brand, trade name or specific product. This coding system is used to bill for supplies, ambulance services, etc. not listed in the Procedural Terminology coding system. The final draft of the HCPCS was

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developed around the 1980s by the U.S. government to enable providers to submit claims for these services. Currently, the Secretary of HHS was delegated under the HIPAA legislation for Centers for Medicare and Medicaid Services, (CMS) to maintain and distributes these HCPCS codes. (Exhibit C)

3. Many changes occur each year and the cms.gov website maintains

the National Correct Coding Initiative (NCCI) updated website. This website is updated quarterly due to the many changes in coding and other policies.

4. If you use any of the current procedural coding resources, you may

be able to challenge some of the requirements for enrollment into certain classes.

C. Obtaining the Certified Professional Medical Auditor Credential (CPMA®)

1. In order to sit for the CPMA examination, there are various policies

and regulations along with their guidelines you must have knowledge of. a. Fraud and abuse. b. Federal false claims act. c. Anti-kickback law. d. Stark law. e. Exclusion law. f. Civil monetary penalties law. g. Office of the inspector general (OIG). h. Centers for Medicare and Medicaid services (CMS).

2. There are various medical record documentation standards you

must have knowledge of as well. a. Health Insurance Portability and Accountability Act (HIPAA)

privacy regulations. b. Types and components of medical records c. Accreditation standards.

3. Coding and reimbursement concepts.

a. Procedural terminology coding system and guidelines. b. Evaluation and management. c. Anesthesia. d. Surgery. e. Radiology.

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f. Pathology and laboratory medicine including chemotherapy, psychotherapy and physical therapy.

g. Modifiers. h. Diagnosis coding. i. Physicians at teaching hospitals guidelines.

4. Auditing.

a. Auditing process. b. Statistical sampling, utilization review, RAT and STATs.

5. Risk analysis and communication.

a. Validation of audit results. b. Analysis and report of audit findings. c. Communicating audit results.

6. Practical expertise.

a. Practical audit skills utilizing cases for practical application.

7. Upon enrolling in the CPMA course, you will be responsible for learning all of the required standards and concepts necessary to sit for the examination. Some of the policies and regulations can be found on various websites. a. LexisNexis®, or utilize your state’s official website to locate

other policies or laws utilized in your state, i.e. Attorney General’s Office (AGO).

b. Use other legal programs to perform searches necessary. This is where relationships with various legal personnel will be vital to you. Ask for their opinion as to the programs they prefer.

8. Additional requirements requested by employers.

a. Many businesses will require you to have knowledge of spreadsheets and their programs (i.e. Adobe® and Excel®). Having a certificate of completion in one of these programs can increase your consulting opportunities with numerous businesses.

II. COMMON TYPES OF AUDITING CASES

A. Professional Fees 1. Voluntary requests to review their compliance with SOP in

billing/coding fees for medical/surgical, durable medical equipment, (DME), physical therapy, laboratory, radiology and physical medicine services, etc.

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2. Providing an itemized audit for these fees or actual fees paid to by the provider for supplies/instrumentation can be also requested.

B. Providers Charges of DME

C. Hospital Charges

D. Various Charges Made by a Certain Department Within the Facility, etc. (Hospital or Ambulatory Surgical Clinic)

E. Attorney, Insurance Carrier May Need You to Review Medical Documents Auditing for Compliance in Regard to the Insurance Fees They Are Submitting (Exhibits D and E)

III. COMMON DEFENSES FOR INSURANCE FRAUD CASES

A. “Ignorance” or “I Didn’t Know” Excuses

B. Person Handling the Billing Told Us She Was Certified in Billing or Coding or Both

C. Provider Doesn’t Like to Discuss Money Issues with Their Patients/Clients

D. Provider Attempts to Mitigate the Error by Initiating Refunds to Insurance Carrier Before a Formal Audit by Insurance Carrier Has Been Done

E. The Adjudicator for the Insurance Company Erred in Allowing Payment Authorization

F. Improper or Incorrect Coding Policies Were Learned by Coder or by Another Coder or Biller While Working for Current or Previous Employer

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G. Employers, Coders and Billers Never Attended Seminars to Learn Important Updates in Their Specialty Area

IV. THE ROLE OF THE CERTIFIED LEGAL NURSE CONSULTANTCM IN MEDICAL AUDITING CASES

A. Compile the Evidence into a Formal Review for Merit

1. Obtain copies of all insurance explanation of benefits (EOBs) for all

payments or claims that have been processed by them. (Exhibits F, G and H)

2. If a request is made to uncover the actual fee charged for a surgical

device or implant, a RFP can be made to the purchasing agent for the hospital’s OR or a copy of this purchase order (PO) will be given to the OR. Or, request assistance from those hospital personnel as to who performs reorders for these supplies for their department. Request assistance from the attorney’s paralegal or legal secretary for the RFP if necessary. (See 4 below first.)

3. You may need to request a copy of the insurance company’s or

hospital’s charge master for the year services were provided. The charge master is a list of all services and fees approved by the state’s department of health and hospital’s internal auditing departments for fees charged to insurance carriers, patients, etc. Make sure you obtain the proper year services were rendered. Insurance companies also have and maintain similar reimbursement charge masters.

4. While waiting for documents, review the invoices along with the

insurance claims and match up the Procedural Terminology coding. (Exhibit I) a. Many of the laboratory codes have been updated. For

instance, if your physician wants to order numerous blood tests, there are profiles where many blood tests have been bundled together. Unbundling of these tests is forbidden. Comprehensive metabolic panel (CMP) and basic metabolic panel (BMP) includes specific blood tests that are performed/included together. Some offices try to charge for each blood test.

5. Once you have all of the reports, then you can officially compare

the usual customary and reasonable (UCR) charges. These tables or copies must be submitted with your official report, along with

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insurance spreadsheets or ones you create for your evidence reports.

B. Develop the Report (Exhibit J)

1. Write as you would write a report for an attorney-client. The one difference is the use of spreadsheets, copies of EOBs, uniform billing (UB), etc. as evidence. a. Including spreadsheets, copies of policies in regards to SOP

proper surgical or medical coding and billing with updated policy changes. This is where the NCCI website is handy since it is updated every three months. Plus it is from a federal source cms.gov. Even third party, TPA and Blue CrossBlueShield Insurances utilize the billing and coding policies on this site. There’s an introductory overview of their policies and included is information utilized by these other insurance carriers. How to properly bill and code polices are covered on the website.

b. The AMA owns exclusive rights to the CPT coding system. This organization published the first textbook in 1966. The coding policies and CPT codes and policies can be found at ama-assn.org. If you must communicate with them, the web address changes. Be sure to note which department to use. Only the AMA can make changes to the CPT coding system. This includes coding policy changes.

2. You may be required to have various exhibits ready for an attorney-

client depending on the type of case or charges being litigated (i.e. pictures of orthopaedic implant(s)/devices, anatomical charts, etc.). Obtain copies of surgical procedure(s) taken from a reliable source (e.g., national websites for each specialty/type of surgery, i.e. American Association of Orthopaedic Surgeons (AAOS)).

3. Explain what the equipment or devices are used for.

C. Communicate Your Verbal Opinion Regarding the Audit Findings

1. Give the attorney the facts. The documentation and the dollar amount or grand total of overbilling is important to proceed with filing this case. The insurance carrier(s) will perform their own audit.

2. Next step, what is your evidence? Make copies of the EOBs, along

with provider invoices. Print all the evidence to submit with your formal report. If you have any questions involving proper

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billing/coding SOP, discuss these questions with the attorney-client or a certified auditor or coder.

3. Determine whether or not merit is present for possible insurance

fraud.

4. Should the Department of Banking and Insurance become involved, they will perform their own investigation.

5. Make sure you consult your attorney-client before sending or

submitting reports or evidence to an outside source. It’s best to confirm they received any evidence you’re instructed/approved to submit. A certificate of merit can be used as evidence.

V. INTERROGATORIES AND REQUEST FOR PRODUCTION

A. Interrogatories Directed to the Defense

1. Please state the name, last known business address, and last known home address of any and all physicians and/or personnel who performed billing/coding services and/or surgery for your (Practice) __________ from (Date) __________ to (Date) __________. Use separate sheet of paper for additional personnel/providers.

2. Please include academic credentialing, certification of any/all

physician and/or office personnel performing billing/coding services for (Practice) __________ from (Date) __________ to (Date) __________. Use separate sheet of paper for additional names.

3. Please include copies of resumes and CVs for physicians and

personnel responsible for practice billing/coding services. (Include most recent work history within seven years.) Copies of recent resumes and CVs maybe attached separately.

4. Please include the name of in-house medical billing service,

administrator, business address, business phone number(s), fax number, contact person, personal address, phone number, and cell number. Please provide a copy of their most recent resume or CV with seminars attended in the last three years. Attach a copy of their business advertisement, business accreditation(s), or brochure, and a copy of signed contract.

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5. Please include the name of office personnel or in-house administrator responsible for providing in-house training/education and/or overseeing personnel involved in daily billing/coding educational updates, or policy changes involving coding/billing. Business address, business phone number, fax number, last home address, phone number and resume/CV with educational accreditation/certification along with seminars attended the last three years.

6. Please provide name of training/education/support company

accreditation, certification, supplied by outside company or consultant(s), administrator’s name, business address, business phone number, fax number, last known home address, home phone/cell phone numbers, federal or state tax ID number and frequency of educational training provided.

7. Please provide the name of business and/or company in charge of

providing preventive maintenance and or technical support for computer equipment utilized for billing/coding of providers’ medical business accounts, business address, business phone/fax number, contact person’s name.

8. Please provide name of administrator or employee’s (technician’s)

name responsible for preventive maintenance and educational credentials/records or resume/CV the consultant maintains along with work experience for the last seven years?

9. Please provide the name of medical company and/or billing/coding

program utilized in the provider’s business office. Provide the name and business address of company supplying the program, phone number and fax number along with contact or administrator’s name. Provide records or documentation for frequency of updates to the billing/coding programs files provided by computer company.

10. Please provide the name of any/all defense expert witnesses

providing assistance with medical auditing for medical fees/charges submitted for payment, along with business address, home address and business phone number/fax numbers. Please provide expert witnesses’ resumes and CVs along with certifications, continuing education and seminars attended as required to maintain certifications of credentials, along with a list of attorneys and cases testified/mediated on during the last two years?

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B. Requests for Production Directed to the Defense

1. Please provide job descriptions for office biller and office coder. Include: roles, functions, duties and/or responsibilities. Indicate if your office requires each employee to have and maintain certification in their biller, coder office position. Attach requested information on office stationery.

2. Please include copies of business/office accounts showing

payable/receivable and credits issued, monthly or yearly account flow sheets and insurance EOBs posted from (Date) __________ to (Date) __________ on patient accounts listed in requests for production. Please include copies of all requests for audits to insurance carriers regarding patient insurance payments disputed and the insurance carrier’s response or disposition of audited insurance claim for provider’s professional services.

3. Please provide copies of preventive maintenance documents

completed as to when and how often the billing/coding computer system is maintained by your computer support company? Provide name of office personnel who maintains the medical insurance records backup files, how often these medical billing/coding files are backed up and where they are saved (hard drive, disk, flash drive, etc.).

4. Please provide documentation how often personnel receive

billing/coding support and updates in procedure terminology, ICD. and HCPCS coding. Name of office personnel/consultant, credentials and/or company providing this technical support. Provide consultant’s/company’s business address, business phone number/fax number, last known home address, phone/cell phone numbers and contact person’s name.

5. Please provide copies of practice/office implemented HIPAA

policies regarding emails, maintaining medical and personal health information documents, including medical insurance information, providers’ EOBs, medical patient billing invoices, UBs, and/or copies of electronic or manual medical insurance forms utilized for patient claim submissions/payments and where these documents are secured. Also provide HIPAA office policy regarding inadvertent/accidental release of patient personal health information, including insurance information.

6. Please provide documentation on patient accounts for which patient

insurance carriers have sent demand letters for reimbursement to practice for overpayment. Provide reasons for requests for

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reimbursements. Show what preventive actions have been implemented to cease demand letters for reimbursement from occurring from the medical insurance carriers.

7. Please provide copies of office billing/coding incident, variance

and/or occurrence reports and steps taken to ensure these incidents do not reoccur.

8. Please provide office billing/coding educational materials in teaching/orientating new staff/employees.

9. Please provide a list of current billing/coding textbooks, or medical

billing/coding references, and/or websites utilized in the performance of medical billing/coding duties.

10. Please provide a copy of the provider’s fee schedule from

Medicare/Medicaid, commercial insurance carriers and BlueCross/BlueShield carriers the office submits fees/charges to. Please include fee schedule(s) for DME and/or liability insurance fee schedules (Date) __________ to (Date) __________.

VI. RECOMMENDED QUALIFICATIONS FOR CLNC® SUBCONTACTORS FOR EXPANDING YOUR CLNC® PRACTICE INTO THE MEDICAL AUDITING FIELD

A. How to Find the Right CLNC® Subcontractors to Help Build Your

Medical Auditing Business

1. Certified case manager, Workers’ compensation case manager, pre-certification employee with heavy coding experience or CLNC® consultant who worked in the medical billing/coding field.

2. Certified as a professional coder (CPC®).

3. Registered with a well-known medical auditing, billing or coding

school/course.

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VII. RESOURCES

A. Associations and Organizations

1. American Academy of Professional Coders. aapc.com.

2. Centers for Medicare & Medicaid Services. cms.gov. a. You will need to perform a search for the National Correct

Coding Initiative (NCCI) or Correct Coding Initiative (CCI). The file name changes with updates.

b. cms.hhs.gov/ncci.asp or after opening cms.gov website, perform search for “medlearn” file. With next page, search for “national correct coding initiative” or “ncci or cci” file.

c. This is a learning/training website set up in the early 1990s for all providers to have access to correct and proper standards of practice re: charging for billing/coding services. Since so many changes occur, this website is updated every three months. You’re looking for a pdf file that is an introduction to proper coding. The SOP for proper billing or coding on this site is utilized by all insurance carriers. See the website introduction.

3. Medicare.

medicare.gov.

B. Authoritative Textbooks

1. Abernathy, Beverly, et al., Healthcare Common Procedural Coding System. (HCPCS), Level II Expert. 2014 AAPC. Salt Lake City, UT 2015.

2. Abernathy, Beverly, et al., International Classification of Diseases

10th Revision, Clinical Modification, (ICD-10-C.M.), 10th Edition, 2014 AAPC. Salt Lake City, UT. 2015.

3. Agbona-Johnson, Geanetta, CPC, et al., HCPCS. Healthcare

Common Procedural Coding System, Level II Expert, AAPC. Salt Lake City, UT, 2015.

4. Chin-Johnson, Lisa, et al., American Medical Association *CPT

Current Procedural Terminology, Professional Edition, 41st Edition. Chicago, IL 2015. Procedural Coding Expert Manual, AAPC utilizes the CPT codes

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and coding system since their system is recognized as the official coding system for all insurance carriers with a few exceptions (e.g., selected Medicare claims submissions).

C. Website

1. National Correct Coding Initiative, (NCCI). CMS.gov. Website maintained by Medicare. Also, under Medlearn. Website for updates completed every three months due to the constant changes in coding information. Go to: cms.gov and perform search for medlearn, ncci or cci link. There is a tutorial link on proper coding on this site. Very large file. Link or string is constantly changing in name.

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Exhibit A Modifiers

Exhibit courtesy of American Academy of Professional Coders.

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Exhibit B Discharge Codes

Exhibit courtesy of American Academy of Professional Coders.

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Exhibit C Drug J Codes

Exhibit courtesy of American Academy of Professional Coders.

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Exhibit D Letter #1 from Attorney

December 15, 2015

John Merlin II, Esq. Merlin and Collins LLP Two Industry Way W.

Eaton Place, NJ 11111-1111 Helen C. Strasko, RN, CPC, CLNC Atlantic Legal Nurse Consultants & Medical Insurance Auditing Manchester, NJ 22222-2222 RE: Client’s Name File #: __________ Dear Mrs. Strasko, As per my phone call to you earlier today, I will be forwarding to you the provider’s invoices and the insurance claims, explanation of benefit forms you requested. I am pleased you will be able to provide this service. I’m looking forward to your phone call upon the completion of your audit of these fees and charges. If you should find there are any additional invoices or insurance forms you also need to complete your audit, please do not hesitate to call my office. As I related to you in our conversation, my client is quite anxious to have a knowledgeable person in billing/coding look over these fees. Sincerely, John Merlin II, Esq. Merlin and Collins LLP Two Industry Way W. Eaton Place, NJ 11111-1111

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Exhibit E Letter #2 from Attorney

December 28, 2015

John Mitchell, II, Esq. Wilentz, Goldman and Smith, PA

123 Meridian Corner Eaton Place, NJ 11111-1111

RE: Client’s Name File Number:____________ Helen C. Strasko, RN, CPC, CLNC Atlantic Legal Nurse Consultants & Medical Insurance Auditing Manchester, NJ 08759-6133 Dear Mrs. Strasko, As per my phone call and subsequent letter to you, I have requested your expertise in reviewing my client’s recent fees for surgery this past _____________ performed at _______________Medical Center in _____________, NJ. My client contacted me after receiving this invoice for fees due after the insurance paid their share. Naturally, this client is upset and it appears as though the secondary insurance has not been billed yet. It would seem as these surgical fees might possibly be excessive and if you could review them for me, I’d be most grateful. I look forward to hearing from you soon with your verbal report. I thank you for performing this audit for our office. This client is a personal friend of ours and your expertise in this matter is appreciated. Sincerely, John Mitchell, II, Esq. Wilentz, Goldman and Smith, PA 123 Meridian Corner Eaton Place, NJ 11111-1111 Enclosures: Invoices Insurance EOBs

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Exhibit F Sample Statement

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Exhibit G Nurse Practioner’s Fees

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Exhibit H Surgeon’s Fees

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Exhibit I Surgical Provider Spreadsheet for Attorney

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Exhibit J Sample Report

Atlantic Legal Nurse Consultants & Medical Insurance Auditing

Helen C. Strasko, RN, CPC, CLNC 2349 Woodland Road

Manchester, New Jersey 08759-6133 (O) 732.278.9757 (F) 732.908.3676

January 20, 2016 Attn: John Mitchell, II, Esq. Wilentz, Goldman and Smith, PA 123 Meridian Corner Eaton Place, NJ 11111-1111 RE: Client’s Name File #:___________ Dear Mr. Mitchell, II., Esq. I have reviewed the surgical fees and/or invoice(s) you submitted to me as requested. As you and I discussed during my verbal report to you last Friday, January 15, 2016, the surgeon’s billing and coding departments have made numerous egregious errors in the medical insurance codes submitted for payment. I was able to compose a simplistic flowsheet as you requested and pointed out these numerous errors in billing and coding. Many SOP in the proper coding regulations have been violated. I will provide these policies to you below and why there are many fees submitted that are simply not allowed. 1. It is always best for medical/surgical offices to have in their offices current

Procedural Terminology, ICD-10-CM and HCPCS textbooks. Many billers/coders rely on their computerized medical billing/coding programs. Unfortunately these programs contain numerous coding errors and glitches in the processing of medical/surgical claims. There have been numerous changes to the ICD-10-CM codes and Procedural Terminology Codes for 2015. The adjudicators, who are supposed to have formal training to properly process claims, receive little to no formal training. Many adjudicators merely rely on the provider’s offices submitting accurate claims to be processed for their coding and billing fees. Therefore, reimbursements are being allowed in violation of the SOP for proper coding, by these adjudicators as well.

2. RE: Add-on Codes: There are very special circumstances when a surgeon maybe able to add Modifier 51 onto the CPT code in order to charge for more than one procedure on different anatomic sites, or when performing different related procedures on the same anatomic site and the provider performing the

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same procedure on the same anatomic site multiple times. Add modifier 51 to subsequent procedures. e.g. second, third, fourth procedure. These additional procedures will be processed for 50% of their respected fee. Do not report modifier 51 with modifier 50, with add-on codes, or with codes that are modifier 51 exempt. Do not report modifier 51 with add-on codes. Report the most complex procedure code first. Do not report with modifier 59 used for distinct procedural service. A “Special Report” should be submitted by the surgeon when this modifier is used to explain why the procedure or service was distinct or independent from the other services performed on that day. Used with any other non-Evaluation/Management (E/M) service. Provider’s documentation must support:

Different encounter or session.

Different surgery or procedure.

Different organ system or body site.

Separate incision or excision.

Separate lesion.

Separate injury. Modifier 59 is used to report procedures or services not typically reported together, but are appropriate in specific situations. Therefore, the coder was unable to utilize these additional CPT codes since neither one of these modifiers that normally would have been used, applied to these coding situations. Lastly, on CMS.gov Medlearn website, they clearly state in “Section 40-6 Claims for Multiple Surgeries.” (Rev.1, 10-01-03) B3-4826, 15038, 15056 along with the most revised CMS.gov NCCI policy update: A. General-multi surgeries are separate procedures performed by a single

physician or physicians in the same group practice on the same patient at the same operative session(s) or on the same day for which separate payment may be allowed. Incidental surgeries or components of more major surgeries are not separately billable.

B. The statement, “separate procedure” includes a parenthetical statement

that the procedure can be performed separately, but should not be reported when a related service is performed. A separate procedure should not be reported when performed along with another surgical procedure in an anatomically related region through the same skin incision or orifice, or surgical approach.

In closing, these policies for proper coding and billing for surgical procedures will be quite useful should you go forward with your client’s case. If I can be of any additional assistance, please do not hesitate to call on me.

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I am truly grateful you sought my assistance early into your client’s case. I would recommend any additional invoices, UB forms from Medical Centers, ASC, etc., be forwarded to me. It is imperative any discrepancies in medical/surgical fees be thoroughly investigated as soon as possible. The insurance companies do not perform manual audits and depend solely on their computer programs/adjudicators to discover questionable fees being submitted. I would be able perform compliance auditing as well. Thus ensuring the medical documentation is appropriate and is in compliance with submission of proper fees/claims submissions. Thank you again. Respectfully, Helen Strasko, RN, CPC, CLNC Enclosures (2)