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DOING BUSINESS


Code Properly to Prevent Lost Revenue Tips for reducing rejection/denial rates BY ANGELA MATTIODA


An ASC’s coding staff plays a key role in avoid- ing


claims denials. By


ensuring accurate cod- ing and data entry, an


ASC is more likely to receive correct, complete payment for services ren- dered. Any number of coding-related issues might cause a loss of revenue. Understanding these issues and how to effectively respond when they arise will help keep cash flowing in and denials away.


Correct CPT Codes ‘Not Authorized’ Surgeons intending to perform a spe- cific procedure might need to change their plan after starting surgery. Any such change could result in a denial since the procedure performed dif- fers from the authorized procedure. In many specialties and when deal- ing with health maintenance organi- zation (HMO) policies, it would be appropriate to request an authoriza- tion for a range of codes that relate to the intended procedure. This can elim- inate the possibility of authorizing the incorrect code.


the


If there is a discrepancy between issued


code(s) and authorized


code(s), the biller should communicate immediately with the surgeon’s office staff or the HMO’s primary care refer- ring physician to request adding the code to the authorization before it pro- cesses and is denied. If you must wait for the denial to appeal, make sure your appeal is detailed. Include the authorization timeline of the original code, an expla- nation of why a different procedure was performed and documentation to support medical necessity.


Assign the screening diagnosis as the primary diagnosis, even if there are findings, and the diagnosis describing the findings as the secondary diagnosis.”


— Angela Mattioda Surgical Notes RCM


Colonoscopy Screening Versus Diagnostic Coding Discrepancies Another common denial relates to cod- ing colonoscopy procedures. Screen- ing and diagnostic colonoscopies are processed based on the patient’s spe- cific insurance policy. If there are lower GI symptoms indicated in the operative report or history and physi- cal (H&P), the screening will turn into a diagnostic colonoscopy. A screening colonoscopy may be covered by the patient’s policy whereas a diagnostic colonoscopy may not be covered, leav- ing the patient with a higher out-of- pocket responsibility. The Centers for Medicare & Medicaid Services (CMS) has specific guidelines related to pre- ventative procedures (found at www. medicare.gov/coverage/colorectal- cancer-screenings.html) that many payers follow. To avoid denials for colonoscopy procedures, verify benefits for both screening and diagnostic colonosco- pies, and obtain the appropriate autho- rizations. Verify the benefits with the screening diagnosis code (Z12.11) ver- sus a diagnosis code that will be used as the secondary that indicates find- ings (K63.5). This upfront discussion with the payer will help you deter- mine how the payer will handle the


case in either event. Educate patients that their out-of-pocket cost could sig- nificantly increase if there are findings during their screening colonoscopy. If the colonoscopy is performed for diag- nostic purposes due to presenting signs or symptoms, the procedure will typi- cally be covered as a surgical service under the patient’s benefit plan. Coders should be knowledgeable


of coding guidelines to ensure the cor- rect use of diagnosis codes, order of diagnosis codes and use of applicable modifiers. Assign the screening diag- nosis as the primary diagnosis, even if there are findings, and the diagnosis describing the findings as the second- ary diagnosis (Note: This can change depending on Medicare local coverage determination [LCD] or payer require- ments). Some payers might still pro- cess according to the original reason for the colonoscopy (e.g., screening).


Unlisted CPT Codes or Non-Covered Procedures It is never compliant to choose a listed code because it is “close” to the per- formed procedure. Recognize in advance when an unlisted code will be used and obtain the appropriate authorization. If the claim is denied, submit an appeal and include a copy of the operative report, H&P and other clinical notes that jus- tify medical necessity. In the appeal, it might be necessary to provide a com- parable procedure code and descrip- tion and note the differences between the procedure performed and the com- parable code. If the unlisted procedure involved more time or expertise, that should also be in the appeal. The com- parable procedure code should have a similar approach and anatomical site.


The advice and opinions expressed in this column are those of the author and do not represent official Ambulatory Surgery Center Association policy or opinion. 22 ASC FOCUS APRIL 2018 |www.ascfocus.org


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