Prevent Denials with More Accurate Medical Coding

Lisa Eramo June 14th, 2012

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Prevent denials and increase your practice revenue with more accurate medical coding

Many physicians don’t want to admit that coding is a necessary—and even crucial—aspect of running one’s practice. Instead, they often choose to focus entirely on providing good patient care.

However, coding is often the backbone of a physician’s practice. Inaccurate medical coding can lead to denials and potentially a substantial loss of revenue over time.

Deborah Robb, BSHA, CPC, director of physician services at TrustHCS in Springfield, MO, says she often works with physician practices that experience denials because they don’t place enough of an emphasis on compliant coding and overall data integrity. Robb, who regularly contributes to the company’s blog, The Coding Compliance Blog, provides these pointers for how to get back on track and keep the cash flowing.

1.       Don’t rely entirely on the claim scrubber. Claim scrubber software analyzes data on a claim to ensure accuracy before the claim is submitted. Although scrubbers catch many errors before claims are sent, they don’t catch 100% of them, says Robb.  

For example, the software can’t scan documentation to ensure that a particular ICD-9 code is justified. Thus, physicians may be surprised when certain codes pass through the scrubber because they meet medical necessity only to be subsequently denied by insurers because documentation simply doesn’t justify their assignment, she adds.

Claim scrubbers also don’t catch every modifier-related error. Although the software flags claims for which modifiers might be missing, it won’t catch errors on claims for which modifiers are already appended incorrectly. 

Robb says many practices incorrectly append modifier -59 (distinct procedural service) as a general rule of thumb when more than one service is performed. By doing so, the practice is paid 100% for each service rather than 100% for the first service and 50% for any additional services. However, automatically appending modifier -59—as well as appending it when a physician only performs one service—will most likely send up a red flag for auditors, she adds. 

Coders and those charged with coding and billing functions within the practice should take the time to review proper modifier usage. In particular, check out free Webinars about modifier -25 (significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service) and modifier -59, which the American Medical Association (AMA) offers.

2.       Designate the principal diagnosis. The principal diagnosis must indicate the reason the patient presents for the visit on that particular day, says Robb. Although physicians may document or check off a list of multiple diagnoses on a superbill, what they don’t do is indicate which diagnosis is principal. Physicians must number the diagnoses, and those numbers must indicate the order of importance, she adds. This will help avoid medical necessity denials.

3.       Watch for invalid codes. Invalid codes refer to codes that have been deleted, and in most cases, replaced by new codes. Robb says outdated superbills often perpetuate errors due to invalid codes. At a minimum, superbills should be updated in October when new ICD-9 codes become as well as in January when new CPT codes become effective. If physicians perform new procedures in their practices, CPT codes to reflect those procedures (as well as any new ICD-9 codes to justify them) should be added to the superbill immediately.

4.       Establish a procedure to identify non-covered codes. Non-covered codes refer to codes that payers simply won’t cover. Patients presenting for non-covered services should receive an Advanced Beneficiary Notice (ABN) indicating that they are responsible for payment. For example, if the practice anticipates a denial due to lack of medical necessity, the patient should receive an ABN so the practice can report the service with modifier -GA. By appending this modifier, the practice indicates that the patient received and signed an ABN. Practices should also report it when a patient receives an ABN but refuses to sign it. Reporting this modifier ensures that upon denial, Medicare will automatically assign liability to the beneficiary.  

Practices that don’t obtain a signed ABN in anticipation of non-covered services will receive a denial and have no option to bill the patient. For more information about modifiers, visit the Wisconsin Physicians Service (WPS) Insurance Corporation’s Web site. WPS is a Medicare Administrative Contractor for Iowa, Kansas, Missouri, Nebraska, Indiana, and Michigan.  

Lisa A. Eramo is a freelance writer and editor specializing in medical coding, health information management, and other healthcare regulatory topics. Visit her website at http://lisaeramo.wordpress.com/. Lisa wrote most recently for Getting Paid on Three Simple Tips for Managing Denials. Lisa has also written on Understanding RVUs: Ensure Accurate Reimbursement for the E/M Services You Provide.

You can learn more about denial management in our upcoming webinar, “Stop Denials in Their Tracks: Get Paid the First Time by Health Care Insurers.” Register now to learn about this important topic with expert speaker Betsy Nicoletti, M.S., CPC.

Related Posts:

Why Isn’t “Dog Bite” a Valid Diagnosis Code? Diagnosis Coding Rules Explained

Denials: A Removable Obstacle on the Road to Getting Paid

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