Why can't payers do things right? Maybe you can help
February 1, 1997 4 minutes read
Why can’t payers do things right? Maybe you can help
Using wrong’ codes can get claims paid sooner
If you haven’t heard yet, the annual coding demolition derby is in full swing. Unfortunately, this is the season when insurers and third-party administrators begin returning batches of outpatient claims bearing those brand-new HCPCS and ICD-9-CM codes.
The returned claims are marked "Rejected," and the reason given is usually invalid coding. But as every frustrated business office manager knows, sloppy coding isn’t responsible for most of the returns. The HCPCS and ICD-9-CMs that get documented on claims may be absolutely correct, but the claims get returned anyway.
It’s the payer who most often hasn’t entered the revised codes into his own claims processing system. Therefore, the claims are automatically coming back as improperly coded. And this year like every year when this happens, it’s costing your facility more in extra time and work to make it to the finish line.
Carriers drag their feet
"There’s no easy solution to this problem," says Dody A. Goldmeyer, MHS, RRA, director of HCPCS outpatient reimbursement with MC Strategies, a health care consulting firm in Atlanta.
Medicare carriers in many states are equally guilty of foot-dragging. Providers usually get the new Medicare HCPCS Level II equipment and supply codes from the Health Care Financing Administration (HCFA) in early December. (The CPT and ICD-9s are issued even earlier.) But many carriers and commercial payers don’t switch over until the following April.
The best advice is to submit the claims the first time using whichever codes the insurer will readily accept. If this means using a set of obsolete CPTs or ICD-9s, submit the claims in that manner, Goldmeyer recommends.
Then, whenever the payer officially converts, have your coding edits in place to follow suit, she adds.
But this process involves some preparation. First, you need an efficient internal tracking system to avoid errors and mishaps on your end, says Linda L. Fullam, ART, director of health information management (HIM) and medical records at Springfield (VT) Hospital.
The last thing you want is to permanently confuse the new codes with the old ones in your computer system or send the wrong codes again to the same payer. And make certain that the old codes actually reflect the diagnosis or procedure performed and aren’t just a suitable replacement, Fullam warns.
Keep a separate record
There are four steps considered essential by some financial managers for coding to your payer’s standards. They include:
1. Keep a separate record of the codes used for billing.
At Springfield, the HIM staff adopts the revised HCPCS and ICD-9s as soon as they become official. But they continue to report the corresponding old codes to the business office for billing purposes until an insurer says otherwise.
The new codes are documented into the patient’s permanent record and entered into the facility’s computerized information system, Fullam notes.
But technicians also take the time to place a special notation in the permanent record indicating that for billing purposes HIM used a set of outmoded codes. It reminds HIM that the codes on the claim differ between the patient record and the UB-92 or HCFA 1500 and gives a reason for violation of standard practice.
The handwritten notation is made on a paper copy of the computerized coding screen of the patient record and is accompanied by the patient identification number. A copy of the form is then retained in the permanent file, and another is submitted to the business office.
2. Use temporary charge tickets in clinical departments.
Some payers are willing to accept either an old code or the new one until they formally announce an official conversion date.
In either case, management has to agree on which codes to use and to use them consistently, notes Karen L. Shea, reimbursement specialist at Central Plains Clinic, a 120-physician multispecialty group in Sioux Falls, SD.
Revise the charge tickets
The facility or clinical department’s charge tickets need to be revised to reflect the decision. If a new code is adopted, the ticket should reflect the change. If a commercial payer deviates from Medicare on a specific procedure code when they were previously in agreement, a separate, temporary charge ticket should be printed to reflect the commercial payer’s preference, Shea says.
3. Set an official date for conversion.
Most insurers will inform providers regarding the adoption of new codes and their commencement dates. But business office managers don’t always pass on the information to HIM. Coders need to know about these critical changes to begin documenting their records properly, Shea says.
Therefore, Shea advises that facilities establish an official date in which certain codes will convert in accordance with each payer. The date should be formally announced to all clinical departments and followed up with memos clearly detailing how they replace the old codes. Managers also should schedule orientation sessions with nurses and clinical department heads regarding allowable substitutions and exceptions to the new codes, Shea adds.
4. Update the codes for the entire facility.
At many hospitals, the Charge Description Master (CDM) is so outdated, coding lapses by an insurer would make little difference on a claim. The information would be wrong in either case, says Goldmeyer. For Medicare, the facility’s HCPCS Level II codes are usually automatically assigned to the bill by the CDM. When the CDM is wrong, the information that goes to the carrier is incorrect. HCFA bases payment policies and rates according to such data supplied by providers.
At Springfield, Fullam distributes new copies of the CPT and ICD-9-CM coding manuals to each clinical department during the first few weeks of the new year. She then meets with each manager and revises their CDM in detail, reviewing each component, including the revenue codes, for validity. The process is painstaking but necessary, Fullam says.
Shea, who performs a similar inventory at her facility, sets aside a week to review about 10,000 pieces of data. "It’s better to do the whole thing at once than to leave things hanging," she says.
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