coding for correct payer adjudication -...

Coding For Correct

Payer Adjudication Once and Done

Kenneth D. Beckman, MD, MBA, CPE, CPC

VP/Chief Medical Officer

Assurant Health

• Providers belong to multiple networks

• New partner has not completed network

paperwork by date of service

• Some providers have different network

status depending on:

– Physical address

– TIN number registered with network

Network Status

In Versus Out of Network

Network Status

In Versus Out of Network

• Outpatient facility status

– Physician-owned or Joint Ventures

– Free-standing

– Ambulatory Surgical Centers, imaging centers,

endoscopy centers

• Although the facility may have in-network

hospital and in-network physician

ownership, do not assume the facility is in-

network

Network Status Exceptions

• Exceptions by State and Federal mandates – Emergency - regulatory

• Exceptions by common sense – Non-emergency follow-up of emergency services

– Non-par providers at par facilities: • ER, pathology, anesthesiology, radiology, surgical assistants

• Exceptions by contract – Network adequacy

• Sub-specialists

• Distance from insured’s policy address

Contract Denials

Some Things You May Not Know

• Not much of an issue in Large Group

business

• Small Group and Individual Medical may

have exclusions that providers do not expect

• Short Term Medical plans

• Limited benefit plans

Contract Denials

• Pre-Existing Conditions

– Still exist for adults in Individual Medical plans (until PPACA fully implemented)

– May exist in certain circumstances in Group plans (no prior coverage, late additions)

– Exist for all ages in Short Term Medical plans and Indemnity-type plans

– Definition varies by State and type of plan

– LISTEN when you call to pre-certify a service

Contract Denials

• Continuity of Coverage

– Applicable in Group-to-Group transitions

– May NOT be currently applicable transitioning from Group to Individual or Short Term Medical plan – varies by State of Issue

– However transition from Individual Medical to Group is usually considered Creditable Coverage.

Contract Denials

• State of Issue – All states have mandates that apply to ERISA-

exempt plans including Individual Medical

– However, some Individual Medical plans are issued through a ‘situs’ state that differs from the state of residence and therefore state-specific mandates may or may not apply.

– Watch for Individual Medical plans referred to as ‘Association’ plans

Contract Denials

• Certificate Exclusions

– General exclusions

• Cosmetic, Experimental/Investigational

– Specific exclusions

• Maternity, Behavioral Health, Dental

– Very specific exclusions

• Genetic screening, hazardous activities, breast

reduction, cranial helmets, etc.

Contract Denials

• Currently allowed in some states in

Individual Medical plans:

– Special Exception Riders (SERs)

• allows an insurer to accept an applicant who

would otherwise be denied coverage.

– Condition Specific Deductibles (CSDs)

• Allows an insurer to accept an applicant who

would otherwise be declined coverage.

Contract Denials

• Limited Benefit Plans

– Currently exempt from PPACA regulations

– May (or may not) continue to exist after

full implementation on state-by-state basis

– May have fixed indemnity benefits, per

diems, annual maximums, fee schedules,

etc.

Claims Software Denials

• Assistant Surgeon claims

– Medicare vs. Commercial payers

– ACS tables – SOMETIMES

– Responsibility of facility

– Proprietary software

– Partial approvals

– Multiple assistants


• Lost Modifiers

– Be aware that second and subsequent

modifiers may be lost:

• Conversion of paper to electronic claims by

intermediary

• Transmission of electronic claims

• Limitations of payers internal systems


• Base and Add-on codes

– Paper bill issue

• 6 lines per CMS-1500

– May also be incorrect submission issue

• Add-on without base

• Multiple units of base instead of add-on


• Automated lab interpretations

– Area of Controversy

– Pathologists charging per lab study for

services not specific to individual patient or

individual test

• Quality oversight

• Lab oversight

• Originated with Medicare A vs. B issues


• Phlebotomy fees

– Some software programs deny phlebotomy when performed by same provider as laboratory analysis

– If office performs blood draw and reference lab performs tests then covered

– Claim problems arise with TIN and NPI issues in large practice settings that have separate lab with same ownership


• Handling/conveyance fees (99000 - 99002)

• On-call services (99024 – 99026)

• Office hour charges (99050 – 99060)

• Special reports (99080)

Correct Claim Submission

Incorrect Claim Adjudication

• Although the provider submitted correctly

and payer processed what was received

correctly, errors may occur in the

transaction process

• Most paper claims are converted to

electronic claims by intermediary

• Many PPOs re-price claims before sending

them to the payer

Bundling

• Laboratory Panels

• Routine vital signs (pulse

oximetry)

• E+M codes

– Preventive service + E/M service

Bundling

• Surgical procedures

– Bone marrow aspiration and biopsy • 38220 – aspiration ONLY

• 38221 – biopsy

• Separate Procedure • “Some of the procedures or services listed in the CPT code

book that are commonly carried out as an integral component of a total service or procedure have been identified by the inclusion of the term ‘separate procedure.’ The codes designated as ‘separate procedure’ should not be reported in addition to the code for the total procedure or service of which it is considered an integral component.”

Box 21 -> 24E Diagnosis Pointer

• Very common problem

– Providers list all diagnoses from Box 21 in Box 24 for every claim line, usually chronologically (1234)

– Many payers process each claim line by the FIRST diagnosis code

– Results in denials for mismatched ICD - CPT

• Mastitis 611.0 – IUD insertion 58300

– Results in lower claim adjudication if certificate has different benefit levels for different services (eg medical vs. mental health)

Box 21 -> 24E Diagnosis Pointer

• Example

– Diagnosis 1 = V70.0 General Medical Exam

– Diagnosis 2 = 786.07 Wheezing

– Claim line 1 = 99214-33 – office visit

– Claim line 2 = 71020 – chest x-ray – 2 views

If both claims lines show diagnosis pointers as 1,2, some claims systems will deny the chest x-ray on the basis that it is not indicated as part of a routine general medical examination.

Claim line 2 should not include diagnosis 1

Modifier Mania

• Modifiers that affect Amount of Payment

– 22 increased procedural services

– 26 professional component

– 50 bilateral procedure

– 52 reduced services

– 53 discontinued procedure

– 62 multiple surgeons

– 80, 81, 82, AS assistant surgeons

– Anesthesia status modifiers (P1-P6)

Modifier Mania

• Modifiers that affect Eligibility for Payment

– 24 unrelated E/M service during post-op period

– 25 significant separately identifiable E/M service

– 51 multiple procedures

– 57 decision for surgery

– 58 staged or related procedure

– 59 distinct procedural service

– 76, 77, 78, 79 unrelated procedure/ unplanned

return to OR

– 91 repeat lab test

Modifier Mania

• Modifiers that specify location

– RT/LT: Right or left

– E1-4: Eyelid

– FA, F1-9: fingers

– TA, T1-9: toes

– LC, LD, RC: coronary arteries

Modifier Mania

• General rules of order

– Pricing modifiers first

– Payment modifiers next

– Location modifiers last

• Special circumstances

– Global surgery: report 76-79 first

– Multiple price modifiers: report AS/80/81/82 first

Modifier Mania

Wrong use of modifiers

– 26 modifier on code that has no technical

component

– Surgeons not on the same page

• One bills with 62 modifier, other bills with no

modifier

• One bills with 62 modifier, other bills with 80

modifier

Modifier 50 What is the correct way to submit a bilateral procedure?

a. One claim line, modifier 50, charge 150% of base CPT

b. First claim line, modifier LT, Second claim line, modifier RT, charge 100% of base CPT on each line

c. First claim line, modifier LT, Second claim line, modifiers 51 and RT, charge 100% of base CPT on each line

d. First claim line, modifier LT, Second claim line, modifiers 51 and RT, charge 100% of base CPT on first line and 50% of base CPT on second line

e. First claim line, modifier LT, Second claim line, modifier RT, charge 75% of base CPT on each line

Just What is a Unit?

• Parenteral drug unit limits

• Units incorrectly calculated – mostly Rx

– Incorrect units in 24G

– Common problem on parenteral drugs

• J1020 methylprednisolone 20 mg



• J1070 testosterone up to 100 mg

• J1080 testosterone 1cc, 200 mg

These Couples Were Not Meant for

Each Other

• Gender edits

– Male + TAHBSO

• Age edits (E/M and/or procedure)

– Preventive medicine visits ≠ age

– Influenza vaccine ≠ age

• Illogical diagnosis for procedure

– Mastitis 611.0 – IUD insertion 58300

When is a Consultation Not a

Consultation?

• Consultation without Box 17 completed

• 17. Name of referring provider

• CPT: ‘A consultation is a type of evaluation and management service provided at the request of another physician or appropriate source to either recommend care for a specific condition or problem or to determine whether to accept responsibility...’

• Medicare and Consultations

• Some software will reject codes 99241-99255 if Box 17 is not completed

Laboratory Claim Issues

• NPI/TIN same for OV and lab tests

obviously not performed by the provider

• Box 20 (Outside lab) not completed or

shows NO, yet lab reports are from a

reference lab

• Dipstick urinalysis – using dipsticks with

parameters not under 81000 (creatinine)

Medicare Codes on

Commercial Claims

• CMS has developed specific HCPCS codes

to provide coverage for preventive care

services where the office visit is not a

benefit

– G0101 – cervical cancer screening

– G0102 – digital rectal exam

– Q0091 – obtain Pap smear

Medicare Codes on

Commercial Claims

• ACOG: Non-Medicare Payers:

Code Q0091 should not be reported to private

payers for pap smear collection. The collection of

a pap smear is included in the E/M or preventive

medicine service.

• Some private payers do reimburse for the Q0091

code. In such cases, ACOG strongly recommends

obtaining the guidelines for that specific policy in

writing.

Medicare Codes on

Medicare Claims • ACOG: Q0091 is a code developed by Medicare for services

provided to Medicare patients. Medicare does not reimburse for

preventive services, such as those reported with CPT-4 codes

99384 – 99397. Medicare allows payment of code Q0091 as an

exception to its general rule. Providers should report code

Q0091 to Medicare for the collection of screening pap smears

for Medicare patients.

• However, collection of a diagnostic pap smear for a Medicare

patient (performed due to illness, disease, or symptoms

indicating a medically necessary reason) is included in the

physical examination portion of a problem-oriented E/M service

and is not reported or reimbursed separately

HCPCS Codes

• In addition to CMS specific codes, some

commercial carriers may not accept S-codes

(developed by BC/BS Association, Aetna

and HIAA to report drugs, supplies or

services for which there are no national

codes)

• Including a charge for Informational codes

– A necessary evil of automated claims

Payer Errors

• Claims software auto-adjudication

– Vendor issues

– Payer modification issues

• Processor instruction issues

– Errors are system wide

• Processor error

– To err is human

• Insurer clinician incorrect determinations

GIGO

• A simple rule of life: if it comes in screwed up, the odds are reasonable that we will screw it up more

– Co-surgeons: one bills with -62 modifier, one bills with no modifier

– Employed surgical assistant billed with surgeon Tax ID and surgeon PIN

– Modifier -26 added to professional services only CPT code

Colonoscopy

• Failure to use 33 modifier when pathology found on screening colonoscopy

• Difference between a ‘screening’ and a ‘surveillance’ colonoscopy under Health Reform (see excellent article in March Cutting Edge)

• Different payment ‘buckets’ for pre-scope office consultation and pathologist fee

Anesthesia Emergency

• +99140 Anesthesia complicated by

emergency conditions

– ‘An emergency is defined as existing when

delay in treatment of the patient would have

lead to a significant increase in the threat to life

or body part.’

– Being submitted for every unplanned C-section

even when performed for Failure to Progress

Maternity Care

• OBs billing for urinalysis with each prenatal

visit

• OBs billing an E&M code for the first visit

with the diagnosis ‘Absence of

Menstruation’

• CPT: ‘Antepartum care includes the initial

and subsequent history....routine chemical

urinalysis

Maternity Care

• ACOG: The initial OB visit may be reported as an E/M service

under certain conditions. Even if the patient has taken a home

pregnancy test, the initial visit may still be billed as an E/M

service as you will be officially confirming the pregnancy.

• When coding for the “initial ob visit”, there are a few things that

have to be taken into consideration. First you have to determine

if the patient is there for a confirmation of pregnancy or if the

pregnancy has already been confirmed. The second thing that

needs to be determined is if the OB record has been

initiated. Once this has been established you can determine how

the visit should be reported.

Maternity Care • If a patient presents with signs or symptoms of pregnancy or

has had a positive home pregnancy test and is there to confirm

pregnancy, this visit may be reported with the appropriate level

E/M services code. However, if the OB record is initiated at

this visit, then the visit becomes part of the global OB package

and is not billed separately.

• If the pregnancy has been confirmed by another physician, you

would not bill a confirmation of pregnancy visit.

• The confirmation of pregnancy visit is typically a minimal visit

that may not involve face to face contact with the

physician The physician may draw blood and prescribe

prenatal vitamins during this initial visit and still report it as a

separate E/M service as long as the OB record is not started.

Maternity Care

• Assistant surgeons for C-sections using a

global maternity code with the 80 modifier

instead of the C-section only code

• Complications of Pregnancy certificate

issues

Multiple Gestation Coding

• ACOG:

– Both vaginal: 59400 or 59610 for Twin A and 59409-59 or 59612-59 for Twin B. This method of coding communicates that one global maternity package is being billed along with an additional vaginal delivery (without antepartum care and without postpartum care)

– One vaginal and one cesarean: 59510 or 59618 for Twin B and 59409-51 or 59612-51 for Twin A. This communicates that both a cesarean and a vaginal birth were performed.

– Both cesarean: 59510 or 59618 only because only one cesarean was performed. If the cesarean was significantly more difficult, a modifier 22 should be added to this code. An operative and special report should also be submitted with the claim that describes the significant additional work.

• One major problem we see with appeals is that the individual who coded the original claim is not handling the appeal.

• Providers provide

• Coders code

• Billers bill

• Appealers appeal

• The larger the provider organization, the more commonly these roles are separated.

How NOT to Submit an Appeal

• Don’t read and understand the reason for

the denial

• Argue medical necessity of the services

when that was not the reason for denial

• Assert service was pre-authorized when you

have not listened to the call


• Appeal every denial (at least twice)

– Even 1¢ information codes

• Don’t wait a reasonable time (typically 30

days) before resubmitting a claim or

resubmitting an appeal

– One of the most common EOB messages used

is denial of submission as a duplicate claim



• Use form letters

• Quote non-applicable regulations

• Threaten

• Submit altered medical records

The Bottom Line

• Everyone wins with correct claims

submission and correct claims adjudication

– Auto-adjudication cuts payer’s overhead

– Appeals increase overhead for both payers and

providers

Observations

• No statistics to support this, but my sense is

that 95% of the appeals that I uphold were

not submitted by individuals with CPC after

their name.

• Two-fold problem

– Providers do not hire CPCs to code claims

– Even if the CPC coded the original claim, the

CPCs are not handling the appeals

Observations

• Please remember that in my capacity, I see

only the problems.

• Over 90% of claims submitted are auto-

adjudicated and never are touched by

human hands.

Thank you for your time.

I will be happy to answer any

questions in whatever time we

have left.

Kenneth D. Beckman, MD, MBA, CPE, CPC

Chief Medical Officer, Assurant Health

[email protected]

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