DOING BUSINESS


Unfortunately, Medicare will not pay unlisted codes and, as noted earlier, payers often follow CMS guidelines. Many payers will process the claim based on their fee schedule, which typ- ically does not cover unlisted codes.


Improper Coding of Bilateral Procedures Payers often have different guidelines on billing for bilateral procedures. Some might require reporting two-line items while others will require one- line items with the appropriate mod- ifier. CMS ASC coding guidelines require the use of right (-RT) and left (-LT) modifiers.


When billing the Department of Labor (DOL), ensure its authorization exactly matches the claim. DOL might authorize a bilateral procedure to be billed with modifier -50 or a bilateral to be billed with -RT/-LT modifiers on two-line items. The claim must be billed exactly as it was authorized.


LCD/NCD-Medical Necessity Denials Coders and billers should communicate with the provider and provider’s office to discuss LCD requirements. The more knowledge obtained from the provid- er’s office on specific payer policies and its requirements for medical neces- sity, the better. Coders should code specific to the operative report. If the provider omits details in their dictation that would support a diagnosis code payable per the LCD, the claim will be denied. Note: If no LCD is available, coders should check for national cover- age determinations (NCD).


Not Coding per Payer Rules and Contract/State-Specific Regulations Billers must double check payer-spe- cific guidelines and policies to keep denial percentages low. Create a matrix for in-network and out-of-net- work payers that outlines all important and applicable information needed for coding and billing. It should include payment methodology, how the con-


tract handles unlisted/non-covered codes and how payers handle implants and billing requirements. A common example of a rule that should be noted in the matrix is if the payer requires G0260 or 27096 to report a sacroiliac joint injection.


A good practice is for billers to


enter charges in payer groupings to help maintain focus on payer-specific rules. Consider medical


necessity


requirements by payer when reviewing charges. Immediately communicate any potential medical necessity issues to the provider and staff.


Incorrect or Missing Modifiers Modifiers are billed based on payer- specific guidelines. A few common modifier issues involve bilaterals or performing multiple procedures during the same session. An example would be modifier -59, used to indicate the procedure was distinct or independent from other procedures performed dur- ing the same case and to identify pro-


cedures not normally reported together (due to the National Correct Coding Initiative or CCI edits). It would be appropriate to use modifier -59 if a pro- cedure was performed in a different anatomical site/compartment, by a sep- arate incision or for a separate injury.


Stay Cash Positive


Significant cost is tied to reworking claims due to unnecessary errors. The coding and billing team should be certified and have all necessary tools available to ensure clean claim sub- missions. Following best practices and having a strong quality assurance program in place will substantially reduce an ASC’s denial and rejec- tion rate and decrease any impact to a facility’s revenue stream.


Angela Mattioda is vice president of revenue cycle management services for Surgical Notes RCM in Dallas, Texas. Write her at amattioda@surgicalnotes.com.


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