FEATURE Overcome the Top Coding Challenges
Educate, perform audits and ask questions BY ROBERT KURTZ
I
rina Morrow knows that a lot is rid- ing on her ability to consistently
code her ASC’s procedures correctly. “When you have shortcomings in coding, such as incorrect procedure or diagnosis codes being billed out, that can lead to nonpayments, denials or payer audits for our facility,” says Morrow, billing specialist for Abilene Surgery Center in Abilene, Texas. “We try to avoid these at all cost.” With many ASCs running on tight
margins, there is little room for cod- ing mistakes, says Paul Cadorette, director of educational services for mdStrategies in Cypress, Texas. “The biggest danger associated with cod- ing mistakes is a potential loss of rev- enue. No ASC wants to perform pro- cedures and either not get reimbursed at all or get reimbursed at a lower rate than they deserve.”
Getting reimbursed at a higher rate is also undesirable, Cadorette says. “If you have improper coding that leads to inflated reimbursement and then is later identified by a carrier, the carrier will likely recoup payment.” Recoupments typically come out of future payments. If improper coding went undetected for a long period, the money owed can quickly add up. “Now you are look- ing at receiving lower payments for many weeks, perhaps even months— decreases most ASCs do not plan for in their budgeting,” he says.
Challenges Aplenty Unfortunately for ASCs, coders can be tripped up in many ways, says Bob Lathrop, certified coder and compliance auditor for The Coding Network (TCN) in Beverly Hills, California. “Coding is essentially based around either Medi-
care or American Medical Association (AMA) guidelines. They are completely separate sets of guidelines. Payers follow them at their own will, and rules can vary from market to market.” Coders should expect inconsistency across their ASCs’ carriers, Cadorette says. “You can have one major carrier cover a procedure and then have four others that do not. Knowing your car- rier policies can be difficult, and yet following these guidelines is hugely important to getting paid correctly.” One of the most complex coding rules to follow, Lathrop says, concerns the bundling of procedures. “If you do not know these rules, there is the poten- tial to accidentally unbundle the proce- dures, which can trigger edits and deni- als by Medicare, commercial payers or your local government.” Global surgical packages are defined by carriers in their own way. Some carriers might consider the use of implants, drugs and/or sup- plies inclusive to the package, while oth- ers will let them be reported separately. “Coders should not follow a general rule concerning these packages or they will likely either omit items that could be coded and billed for or include items that should not be coded separately,” he says. Morrow cites bundling as one of the top challenges of coding for her ASC, which specializes in ophthalmology. “It seems that each year, more codes are bundled together per the American Academy of Ophthalmology’s (AAO) coding guidelines.”
Compounding this challenge is the need to understand how payers view various coding guidelines, she adds. “Not all of our payers recog- nize certain diagnosis codes or proce- dure codes, even though AAO coding guidelines permit them.”
Cadorette says one of the most com- mon coding issues facing ASCs today concerns new devices and technologies. “Vendor representatives frequently tell physicians and their ASCs that if they use a new piece of equipment, it is bill- able and, then, provide a CPT code to
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