1. Recipe for incorrect claims:
§ No coding experience
§ No medical billing experience
§ No experience in the specialty
§ Lack of communication between the physician and the staff
2. Foundation for correct claims:
§ Communication
§ Accurate documentation
§ Knowledge of the specialty
§ Understanding of the rules
§ Access to the appropriate and current tools
§ Attention to detail
Between the physician and staff:
§ Teamwork
§ Education
§ Communication
§ Appreciation
3. Communication
§ Education and attention to detail is the key to achieve ultimate accuracy. Physicians should know what information the staff requires; the staff should have a basic understanding of the physician’s work.
§ Allow time to communicate, since several issues may arise, among them being coding issues, office operational issues, incorrect and flawed data, and issues with carriers and their reimbursement policies.
4. Appreciation
§ Thank you with a smile can be magic
§ Make your organization more than just a paycheck
§ People perform more efficiently for those they respect
5. Accurate Documentation
§ Reason for encounter
§ Name(s) and code(s) of the procedure(s)
§ Technique: anatomical location and size of needle
§ Drugs: name and amount
§ Patient’s response and progress
§ Revision of diagnosis if applicable
6. Know the rules:
§ HIPAA
§ Unilateral v/s Bilateral
§ Bundling rules
§ Multiple surgery guidelines
§ Global surgery guidelines
§ Assistant surgeon
§ Medical necessity guidelines
§ Services that are site sensitive
7. Essential office tools:
§ CPT Book – Current Professional Version
§ ICD9/10 – Current Version
§ Medical dictionary
§ Anatomy book – easy graphics are helpful
§ CCI – Current
§ CPT assistant
§ Local Medicare bulletin and policy library
§ Worker’s Compensation manual
§ State Medicaid manual and bulletins
§ Available carrier policies, contracts, and fees
8. Optional tools:
§ “Pain Physician” magazine of ASIPP
§ “AAPC Coding Edge” – American Academy of Professional Coders
§ Nancy McGuire’s, “Coding Billing Expert” published by United Communications.
9. First things first:
§ Greet patient nicely, professionally, and promptly
§ Make sure all patient information is correct
§ Copy front and back of insurance card
§ Ask if patient is covered by any other plan
§ Is injury related to work or other kind of accident?
§ Always get second form of ID from the patient
§ Obtain authorization when necessary
§ Have all necessary papers and forms signed by the patient
10. Charge tickets:
§ Be efficient, so more time can be dedicated for follow up instead of tracking down information.
§ Prompt submission of claims, to meet timely filing deadlines and reduce the time in A/R.
§ Accurate claims, doing it right the first time saves time and it prevents unintentional submission of false claims.
§ Referring physician name, UPIN required.
§ List correct place of service:
Office: 11
Outpatient hospital: 22
ASC: 24
§ Update CPT and HCPCS codes every year, include category III CPT Codes, add 5th digits where applicable, and provide space for additional information and/or procedures and diagnosis not listed.
§ Avoid confusion, use proper codes and modifiers.
§ For multiple procedures the physician should link the procedures and diagnosis.
§ ICD9 codes provide the carrier with the reason for today’s treatment or service.
11. Global days:
§ Global days are the number of days where all subsequent treatment for a condition is included in the payment for the procedure.
§ Spinal injection and nerve block procedures (with the exception 62263 & 62264) have 0 global days.
§ Radiofrequency pumps have 10 global days.
§ Pumps and stimulators have 90 global days.
12. Top coding errors:
§ Failure to document services billed.
§ Failure to provide signatures.
§ Consistent assignment to same level of service.
§ Billing as a consult rather than a new patient.
§ Use of invalid codes.
§ Unbundling of procedure codes.
§ Misinterpreted abbreviations.
§ Failure to list chief complaint.
§ Billing services included in a global fee.
§ Use of inappropriate/no modifier for accurate payment.
13. Work comp highlights:
§ Par providers may enter into managed care W/C agreement – those fees are not subject to limits in W/C fee schedule.
§ Special reports and copies may be reimbursed.
§ Treatment must be pre-authorized.
§ Claims require documentation of services attached to claim forms.
§ Follows 100%-50% model of reimbursement for bi-lateral and multiple procedures; modifier 51 for multiple procedures, modifier 50 bi-lateral procedures.
14. 2006 summary of codes:
§ 95990 – Implantable pump refills.
§ 64415 – Brachial plexus injection, single.
§ 64416 – Brachial plexus injection, continuous infusion by catheter.
§ 64445 – Sciatic nerve, single.
§ 64446 – Sciatic nerve, continuous infusion by catheter.
§ 64447 – Single femoral nerve injection.
§ 64448 – Femoral nerve, continuous infusion by catheter.
§ 62263 – Lysis of epidural adhesions multiple days.
§ 62264 – Lysis of epidural adhesions single day.
§ 20552 – Single or multiple trigger point injections one or two muscles.
§ 20553 – Single or multiple trigger point injections three or more muscles.
§ 27096 – Injection for sacroiliac joint, arthrography and/or anesthetic/steroid.
§ 76005 – Fluoroscopic guidance.
§ 73542 – Radiological guidance and interpretation of arthrography.
§ 20600 – Small joint injections.
§ 20605 – Medium joint injections.
§ 20610 – Large joint injections.
§ 76003 – Fluoroscopic guidance for needle placement.
§ 99143 – Sedation w/wo analgesia, intravenous, intramuscular, or inhalation.
§ 99145 – Sedation w/wo analgesia, oral, rectal, and/or intranasal.
§ 72275 – Epidurogram.
§ 72285 – Discography Cervical
§ 72295 – Discography Lumbar
§ 73542 – SI Arthrography
§ 62310 – Single cervical/thoracic injection.
§ 62311 – Single lumbar/sacral injection.
§ 62318 – Injection including catheter placement, cervical/thoracic.
§ 62319 – Injection including catheter placement, lumbar/sacral.
§ 64479 – Injection, transforaminal epidural, cervical/thoracic single level.
§ 64480 – Injection, transforaminal epidural, cervical/thoracic each additional level.
§ 64483 – Injection, transforaminal epidural, lumbar/sacral, single level.
§ 64484 – Injection, transforaminal epidural, lumbar/sacral, each additional level.
§ 64470 – Facet injection, cervical/thoracic, single level.
§ 64472 – Facet injection, cervical/thoracic, each additional level.
§ 64475 – Facet injection, lumbar/sacral, single level.
§ 64476 – Facet injection, lumbar/sacral, each additional level.
§ 64622 – Radiofrequency facet, lumbar/sacral, single level.
§ 64623 – Radiofrequency facet, lumbar/sacral, each additional level.
§ 64626 – Radiofrequency facet, cervical/thoracic, single level.
§ 64627 – Radiofrequency facet, cervical/thoracic, each additional level.
§ 62290 – Injection procedure for discography, lumbar, each level.
§ 62291 – Injection procedure for discography, cervical/thoracic, each level.
§ 64505 – Sphenopalatine ganglion block injection.
§ 64405 – Occipital nerve block injection.
§ 64417 – Axillary nerve block injection.
§ 64420 – Intercostal nerve block injection, single.
§ 64421 – Intercostal nerve block injection, multiple.
§ 64425 – Ilioinguinal and/or iliohypogastric injection.
§ 64612 – Destruction by neurolytic agent, muscles enervated by facial nerve.
§ 64613 – Destruction by neurolytic agent, cervical spinal muscles.
§ 64614 – Destruction by neurolytic agent, extremity(s).
§ 64640 – Destruction by neurolytic agent, other peripheral nerve.
§ 63650 – Percutaneous implantation of electrode array.
§ 63660 – Revision or removal of spinal neurostimulator electrode array(s).
§ 63685 – Placement of stimulator generator or receiver.
§ 63688 – Removal of implanted spinal neurostimulator pulse generator or receiver.
§ 62350 – Tunneled epidural or intrathecal catheter implantation.
§ 62361 – Non-programmable pump implant.
§ 62362 – Programmable pump implant.
§ 62365 – Pump removal.
§ 62367 – Electroanalysis of programmable pump.
§ 62368 – Electroanalysis of programmable pump with reprogramming.
§ 90760 – Hydration infusion, one hour.
§ 90761 – Hydration infusion, each additional hour.
15. Drugs and supplies:
§ Injected drugs are reimbursed if the place of service is the office or clinic.
§ Drugs used for local anesthetic are not reimbursed by Medicare.
§ Medicare does not reimburse separately for surgical trays or supplies.
§ HCPCS codes are used to report drugs to Medicare.
§ Some private payors are now requesting NDC codes.
16. Modifier tips:
§ 25 – Significant service which goes above and beyond the norm.
§ 26 – Professional interpretation only
§ 50 – Bi-lateral, increase fee when billing with this modifier.
§ 51 – Used to report multiple procedures during same encounter.
§ 58 – Staged or related service by same physician during post-op period.
17. Summary notes, document and report:
§ Site of service
§ Medical necessity and appropriateness of services
§ Patient’s progress, response to changes, and revision of diagnosis if applicable.
18. Non-physician providers:
§ Nurse practitioner.
§ Physician’s assistants.
§ Clinical nurse specialists.
§ Medicare reimburses services permitted under state license.
§ Medicare requires NPP’s to take assignment.
§ NPP’s may bill “incident to”.
§ NPP’s may bill under their own provider number.
§ Commercial carriers have varying policies, usually not published.
19. Medical necessity:
§ Services must be consistent with the symptoms or diagnoses of the illness or injury under treatment.
§ Necessary and consistent with generally accepted professional medical standards, for example, not experimental or investigational.
§ Not furnished primarily for the convenience of the patient, the attending physician or another physician or supplier.
§ The service must be furnished at the most appropriate level which can be provided safely and effectively to the patient.
20. Medical records facilitates:
§ Evaluation and planning patient’s immediate treatment and monitor his/her health care.
§ Communication and continuity of care among physicians and other health care professionals
§ Accurate and timely claims review and payments.
§ Appropriate utilization review and quality of care evaluations.
§ Collection of data for research and education.
21. Plan of care:
§ A guideline of what the physician intends to proceed with.
§ Patient’s progress should always be recorded with each visit.
§ Changes in the plan of care are expected and depending on documentation may constitute a visit code.
22. Past and present diagnosis:
§ Accessible to physician.
§ Risk factors identified.
§ Report only the diagnosis that you are treating on insurance claims.
§ Claims to insurance payors should be supported by documentation in the medical records.
§ Someone in the practice must be able to properly link what is done to the patient (CPT Code) to the condition we are treating (ICD-9 Code).
23. Consult v/s referral:
§ A consult is a request to obtain advice or opinion on patient care.
§ A referral is a transfer of complete responsibility of treatment.
24. Consult requirements:
§ Request must be documented in patient’s medical records.
§ Medical necessity.
§ Written report to requesting physician.
§ It must be the referring physicians’ decision who will treat.
§ A consultant may order diagnostic tests and/or initiate treatment.
25. Summary of billing process:
§ Verify all patient demographics and insurance information.
§ Do research on what the insurance needs (referral, authorization, medical notes, etc.) and follow through accordingly.
§ Check to make sure all coding is correct and enter charges.
§ Bill claims.
§ Follow up with reimbursement and contracts, making sure payments are correct.
§ Follow up with denials, to resolve the problems.
§ If need be, involve the patient during the reimbursement process.
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