5 Ways to Strengthen Claims at Orthopedic Surgery CentersWritten by Laura Miller | July 14, 2011
Here are five ways you can build a stronger coding process.
1. Hire coders who are familiar with orthopedic and spine procedures. Specialty knowledge is vitally important to successfully billing for a practice, says Monty Miller, president and co-founder of Momentum Billing. Hire coders who really understand how orthopedic and spine procedures are performed because they must recreate the procedure on the claims. In addition to receiving optimal reimbursements for surgeries, this knowledge helps the coders quickly understand errors made on denied claims, and they will learn from these mistakes, says Mr. Miller. The coders also need to stay at the forefront of the industry and have training in billing changes as they occur.
2. Make sure coders have time to review documentation clearly. Many coding mistakes result from coders who gloss over the CPT definitions. "CPT is literal—they choose their words very carefully," says experienced coder and author of The Field Guide to Physician Coding and developer of The Accurate Coding System Betsy Nicoletti offers the following advicei. Additionally, not linking the diagnosis properly with the service performed can be a common coder error. If this happens, the payor will deny the claim, which will be sent back to the coder. Then, the coder must fix their mistake and resubmit the claim.
3. Have physicians dictate all necessary information on reports. When dictating, physicians should describe the surgical procedure in detail, allowing the coder to clearly visualize the entirety of the surgical encounter. For example, in spine procedures, the surgeon should include the type of approach used (endoscopic, percutaneous, open procedure, etc.), whether the procedure was anterior or posterior, the laterality and if the surgeon operated on more than one level. Physicians should also describe any implants/graft used, and include details such as the type of implant and the number of units used. Finally, the physician's report should also establish medical necessity for the procedure, which needs to be defined through diagnosis codes.
4. Educate coders in-depth on payor regulations. When a payor rejects a billing claim, the coder must research and pinpoint any inaccurate coding and fix the errors, such as bad modifiers or bad diagnoses, says Courtney Henderson, CPC, CPC-P, billing supervisor for Mu Medical Management. Most payors require a physician's note verifying elements of the corrected claim. If the physician mistakenly performed a procedure the payor will not cover, the claim is written off.
Mistakenly billing payors commonly occurs when payor regulations change, such as when Medicare removed the consultation code, ceasing to compensate for consultation visits. Initially, some physicians forgot and tried to bill Medicare using the consultation code. In order to avoid returned claims, Ms. Henderson suggests visiting company websites and becoming familiar with payor rules.
5. Prepare physicians for conversations with coders after claims are denied. Practice coders should also know how to handle denied claims. Claims are denied for a multitude of reasons, and coders may need to refer back to physicians to get updated information. If a procedure is done differently than usual, the coder must know the reasoning behind this change to receive reimbursement from the insurance company. "If the surgery is done in a different anatomical position for one reason or another, there are different units for pain management reimbursement," says Brice Voithofer, vice president of ASC and anesthesia services for AdvantEdge Healthcare Solutions. "Make sure the coders know what you are doing because correct clinical documentation can speed up the payment process."
An ongoing dialogue between coders and pain management physicians is essential for an effective billing process. "The physician shouldn't be surprised when they get questions from the coders," says Bill Gilbert, vice president of marketing for AdvantEdge Healthcare Solutions . "Have a process in place for communication because billing and coding is complicated. There needs to be a dialogue in place for an effective billing process."
Related Articles on Orthopedic Coding:
4 Points on Coding for Knee Injuries
AAOS: 5 Updates on Debridement Coding
3 Clarifications for Orthopedic Injection Coding
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