You could be losing big on those multiple surgeries
Contract stipulations could be the culprit
(Editor’s note: This is part two in a two-part series on unraveling the complexities of multiple surgery claims. Part one appeared in the November issue of Outpatient Reimbursement Management and reported on how some health plans are handling multiple-surgery claims. In this month’s issue, we explore one reason payers are short-changing providers on these procedures.)
A thorny issue outpatient financial departments face is getting payers to see a facility’s multiple surgery claims from a coding standpoint. Some third-party payers seem to have a separate set of rules when it comes to distinguishing a primary procedure from an unrelated one when they occur in the same encounter.
With so much confusion regarding the proper use of the CPT-4 codes in the ambulatory setting, facility coders who usually know better, often feel helpless. "They know the reimbursement isn’t what it should be. But there seems to be nothing they can do about it," says Gloryanne H. Bryant, ART, data quality/DRG coordinator with Columbia-Good Samaritan Hospital in San Jose, CA.
The codes, themselves, aren’t at fault, Bryant says. Using codes or modifiers (if one could be used) that designate secondary or multiple procedures isn’t the issue, she adds.
The confusion often boils down to a difference between the health plan contract and the facility’s claims software. For example, the reimbursement contract will specify that designated surgery codes will be paid as secondary procedures, even if they’re unrelated to the accompanying service. Meanwhile, coders may be following the CPT manual, listing the services as separate surgeries, and the business office will be dropping the bill accordingly.
Facilities face big losses
Unless the payer’s decision is appealed, the facility often takes a loss. Often, the patient accounts department isn’t even aware that the payment isn’t what was anticipated unless there’s an audit. The upshot is that payers are reducing payments although the coding is perfectly legitimate, Bryant says. Providers are losing thousands of dollars this way, she notes.
Health plans decline discussing the ways they generally pay claims. But outpatient accounts professionals agree that payers, especially smaller regional carriers, often interpret multiple surgeries their own way.
If you haven’t already developed options for dealing with this problem, here are four recommendations that may work in defending your coding before payments get cut:
• Coordinate the coding, billing, and contracting functions.
Keeping the coding and billing responsibilities separate is important to some facilities. Coders’ decisions should not be influenced by payment concerns. But someone has to see that both departments are working together. In fact, managers also should include individuals who negotiate the payment contracts, Bryant says.
At many facilities, contracting and patient accounts have no inkling of how the CPT-4 and ICD-9-CM classifications work, Bryant notes. Therefore, someone in health information management (HIM) needs to oversee the three functions so that contracts and bills reflect what the CPT manual states. That way, everyone is working in sync, Bryant adds.
• Separate coding from billing, and go by the book.
However, administrators should still keep coding and billing separate, says Carolyn Burgio, ART, senior coding technician at Samaritan Surgicenters in Phoenix. At many facilities, budget considerations make this separation impractical. But keeping the functions separate eliminates the tendency to artificially upcode a claim to maximize payments. It also places the coding in the hands of full-time experts and helps reduce confusion over questions of primary and secondary procedures.
Also, code according to official CPT guidelines, adds Burgio. The best source is still the Physicians’ Current Procedural Terminology manual, which is published and revised annually by the American Medical Association in Chicago. If payers reject your claims, at least you aren’t guilty of violating proper coding standards, Burgio says. It’s the patient account department’s responsibility to ensure the correct reimbursement.
• Update your claims management software.
If you don’t have a good software program, obtain one, says Bryant. If you have one, update the information to ensure that it conforms to recent changes in your contract. Most vendors of automated coding systems market programs that automatically screen the coding according to individual contract provisions.
A good claims management program reduces the incidence of conflicts between the coding and the contract and will point out where the payer may disagree with your coding practices. But not all software perform these tasks adequately. Check with your present vendor on ways to upgrade this capability to fit your requirements.
If you don’t have the software, assign a coder to the task of monitoring data quality. The individual needs to communicate regularly with the business office to ensure that coded claims reflect acceptable standards and that bills capture appropriate payment levels, Bryant states. The data quality person can lend the coding expertise when appealing payment denials.
• Price your claims strategically.
A reality of managed care is that a portion of every patient claim typically gets denied for payment, regardless of how carefully the claim is coded, and the bill gets dropped, says Andrea Condomitti, CPAM, business office manager at Samaritan Surgicenters.
At Samaritan Surgicenters, billers have adopted the practice of listing the first three most expensive related procedures out of every five on a claim. They submit those CPT codes and write off the remaining two. But to be effective, the practice, which is called zero-pricing, requires the anticipated reimbursement to cover the entire procedure’s fixed costs.
Follow Medicare pricing groups
For example, a sinus procedure may involve a bilateral endoscopy and biopsy, which could amount to $6,000. The facility will submit the codes for only one of the two sides involved in the surgery and write off the rest knowing that the facility will at least recoup its fixed cost.
Another strategy is to follow the Medicare ambulatory surgery center (ASC) pricing groups, which generally reflect resource consumption and relative intensity of procedures by CPT codes. Sequence your codes on claims according to the relative weights of the Medicare ASC rates, Bryant says. And submit copies of the operation report justifying your coding.
"We can bill a health plan up to $1 million, but the carrier will only pay the usual contracted amount. So it’s up to us to cover cost," Condomitti says.
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