ICD-10 Archives - Pinnacle III

Apr 09

ASC Billing Office Process Improvement – Conducting a Quarterly Review

By pinnacleiii ASC Management, Leadership, Revenue Cycle Management No Comments

The saying goes, “Old habits die hard.” But in the ASC billing office, repeating the same mistakes costs time, money, and resources. Hence, the process of identifying process inefficiencies and areas of improvement is a constant responsibility for an effective ASC billing office. It is generally good practice to conduct a complete billing office process improvement evaluation and plan implementation at the end of each financial quarter. At the close of a quarter, there is enough data to review, identify, and correct negative trends. The start of a new quarter provides a clean slate for tracking the impact of the changes three months from now.

Where to begin?

Start by identifying your weaknesses by analyzing available data. This data can come from your patient accounting system and/or clearinghouse. Error tracking allows you to quantify mistakes that prevent clean claims. Reviewing clearinghouse rejection reports may identify trends. If you regularly find the same rejections, log the incidence as well as the resolution changes you make to help you identify and correct the issue. It may also be beneficial to review adjustment journal codes and ensure they meet your tracking needs in case you need to analyze payment or adjustment trends. These metrics can help you identify training opportunities for your staff at all stages of your billing cycle.

Collaboration

In an efficient billing office, a system of checks and balances establishes itself when billing tasks are departmentalized. The schedulers provide the patient and billing information, verification confirms the feasibility of the case under the provided circumstances, coders translate the visit for delivery to the insurance carrier, data entry qualifies the billing information, and accounts receivable ensures maximum reimbursement for the team’s efforts. Each subsequent person that handles the information relies on the previous person’s understanding of healthcare billing. Every individual’s work is verified, but not repeated, in the next step in the process. When each of these groups of people are housed in the same location, collaboration is as simple as looking over the cubicle wall. If your ASC billing office is off-site, the frequency and timeliness in which front office errors are communicated may impact the ASC billing office revenue cycle. It is important to have timely and frequent communication in this scenario.

Cross-train

Requests should not be put on hold when someone is out sick! Besides needing backup to cover absences, cross-training allows employees to understand how people in other roles manage their time and contribute to the success of the team. Transparency among departments and roles invites accountability. The quarterly billing office process improvement review is a perfect time to identify areas where cross-training is needed to fill gaps and/or back up a role.

Empower

A billing office’s process improvement plan success is dependent on the team’s commitment to the improvements. Encourage staff to participate and take charge of change. They perform the tasks that bring the money in the door. Policies and procedures sound good on paper, but execution can reveal unexpected roadblocks. Your team has ideas of how to prevent issues and improve the process. Implement the solutions that will work best for your team and your center.

Re-evaluate

CMS guidelines, fee schedules, CPT/ICD-10/HCPCS codes, pre-certification lists, and coverage policies – this information changes monthly, quarterly, annually. Subscribe to insurance company newsletters and follow medical societies, revenue cycle resources, and vendors. Assign someone to distribute beneficial information to affected groups of people. This may include surgeons, their billing office, facility administrators, and insurance verification specialists, in addition to your own revenue cycle team. The information released may force you to take yet another look at your revenue cycle needs and adjust as necessary!

Summary of Tips for ASC Billing Office Process Improvement

Make it regular. ASC billing office process improvement review should take place on a regular basis, whether conducted monthly, quarterly, or on another schedule.

Review the data. Reviewing rejected claims logs and other data allows you to identify trends and billing office inefficiencies.

Promote team collaboration. Billing office roles will naturally back each other up when operating in sync with collaboration.

Incorporate occasional cross-training. A fresh set of eyes can provide valuable insight into simple changes that can increase efficiency or reduce errors.

Don’t leave out clinical roles. They have valuable insights that can affect coding and thus reimbursement. Evaluate the use of expensive implants and supplies to ensure you are billing and collecting as your contracts allow.

Re-evaluate and update regulatory information. It is crucial to the essential function of the ASC billing office to maintain accurate and up-to-date records when it comes to CMS guidelines, fee schedules, CPT/ICD-10/HCPCS codes, pre-certification lists, and coverage policies. This should also be a part of the regular ASC billing office process improvement review.

The only constant in the healthcare industry is change. When so many professionals rely on your office for the financial deliverables of their organization, as in the ASC billing office, it is imperative to stay up-to-date with industry changes. Regular review of your internal processes is the best way to keep up.

Bethany Bueno, Director of Billing Operations

Aug 30

Love0

Diagnosis Please: It Pays to be Specific!

By pinnacleiii ASC Management, Revenue Cycle Management No Comments

Payors often update their clinical policies in ways that modify how ambulatory surgery centers and physicians must document their interactions with, and sometimes even how they treat, their patients. Staying informed of these updates is crucial to an ASC billing team’s success in obtaining the expected reimbursements. As surgical procedures proliferate, payors are demanding an increased focus on diagnosis specificity. Physicians, surgery schedulers, coders, and billing departments all have a role in expeditiously implementing payor clinical policy changes to ensure reimbursement losses are minimized when policies change.

For example, Aetna’s Clinical Policy Bulletin #0673 changed how ASCs approach meniscectomy cases – procedures billed via CPT codes 29880 and 29881. From Aetna’s perspective, meniscectomies billed without a current injury diagnosis are deemed experimental and investigational (not reimbursable). Therefore, at time of scheduling facility personnel should be able to anticipate whether the meniscectomy case will result in payment or denial based on the patient’s history. Surgeons who add time parameters and other adjectives to the patient’s post-operative notes can clarify the type of tear to ensure medical records and letters of medical necessity do not need to accompany the claim.

The time parameters acute, chronic, acute on chronic, and recurrent are important documentation factors in ICD-10-CM. The difference between billing a specified and an unspecified code may rely on one of these time parameters. Additionally, the distinction in the operative note between an old and a new injury assist coders with proper diagnosis specificity. The indications heading of the operative note is the ideal section to include details regarding injury, trauma, acute, chronic, recurrent, or degenerative conditions.

For example, without knowledge of the patient’s medical history, the postoperative diagnosis “right knee medial meniscus tear” is coded as “M23.231 – Derangement of other medial meniscus due to old tear or injury, right knee.” According to ICD-10-CM coding guidelines, if acute or chronic is not specified, the default diagnosis – chronic – must be assigned. Your surgery center coders should query the physician to obtain greater diagnosis specificity and to gain access to the History & Physical or other parts of the patient’s medical record that clarify the condition.

Ideally, a stand-alone diagnosis reads “medial meniscus tear of right knee, current injury” with a sentence in the indications section of the operative note such as: “The patient is an 18-year-old male who suffered an acute injury to his left knee while playing basketball.” This example yields diagnosis code “S83.231A – Complex tear of medial meniscus, current injury, right knee, initial encounter.”

Other key descriptive words to include about meniscus tears in post-operative documentation are:

Lateral, medial, bucket handle
- Complex, peripheral, bucket handle

Sample key descriptive words to include in post-operative documentation about rotator cuff tears include:

Complete, incomplete, traumatic, non-traumatic, capsule

On average, it takes payors two weeks to issue a claim response (payment or non-payment). When the diagnosis specificity in the operative note is lacking and the carrier requests medical records, an additional 30-60 days is tacked onto the carrier’s payment processing time.

To improve claims processing efficiency, maintain open, direct communication between the patient’s record keepers and the ASC billing department. Regularly review medical necessity denials in the context of clinical policies and operative note documentation. Doing so ensures you are well apprised of payor clinical policy updates and minimizes reimbursement losses.

Bethany Bueno, Director of Billing Operations

Mar 30

Love0

Medical Coders – The Front Line of Your ASC’s Reimbursement

By pinnacleiii Revenue Cycle Management No Comments

Prior to the advent of electronic claims submission – mandated by the administrative simplification portion of the Health Insurance Portability and Accountability Act of 1996 – many claims submitted by ambulatory surgery centers (ASCs) were coded by business office personnel who either relied upon information from superbills provided by surgery center providers or their own hands-on expertise. Today, however, submitting medical claims without the benefit of professional coding expertise can negatively impact your ASC’s reimbursement.

If your ambulatory surgery center employs certified professional coders (CPCs), you’ve positioned yourself well. However, it’s important to ensure their approach is not only outpatient driven, but ASC centric. ASC billing is unique and has become increasingly complex with movement of high acuity cases from inpatient settings to ambulatory venues.

Here are some ways to establish a strong team of certified professional coders for your ASC:

Hire smart.

Certified professional coders are bound by the code of ethics established by their credentialing organization. Their certification denotes implied trust. In other words, you can assume certified coders comprehend the anatomy, physiology, and techniques used in a variety of specialties. Insist on high levels of CPT, ICD-10, modifier, and HCPCS accuracy. Put coders through the paces before you hire them. Have them code sample cases (remove all PHI beforehand) that have been performed in your center and send them to an external auditor to assess coding accuracy.

Perform routine coding audits.

Gauge and manage coding accuracy by auditing often. Internal and external audits identify educational opportunities and ensure upcoding (billing procedures beyond what is documented) and undercoding (not billing procedures supported by documentation) from plaguing your accounts receivable.

Ensure provider documentation is comprehensive.

Medical coders are not diagnosticians! Their role is to provide the insurance carrier with a claim that accurately describes the patient/physician interaction. ASC medical coders depend on the information documented within the operative report to establish appropriate billing codes. When medical necessity denials occur, this can be a sign that the information initially provided in the claim and supporting documentation does not adequately substantiate the billed charge(s). Therefore, when coders approach physicians to request additional information, they are not impugning the physician’s expertise. They are likely seeking one or more of the following:

ICD-10 diagnosis codes which require a higher level of specificity and must be incorporated into the postoperative diagnosis.
More specific procedure headings that sufficiently support the CPT codes billed.

Coders are trained to rely on the information contained in the body of the report. If the headings state something that is not reiterated or fully supported in the body of the report, they are not allowed to bill those codes. To assist them in capturing all billable codes, ensure the narratives in operative reports contain the details necessary to communicate as much as possible about the encounter.

Ensure your coding team knows about new service lines you want to offer.

If your facility is thinking about expansion into new specialties or considering adding high acuity cases, provide ample notice to your coders so they can adequately prepare for these types of cases. They will need to access additional tools to ensure the correct codes are used to describe the services provided. Further, they’ll want to research how to effectively maximize reimbursement of multiple procedures without improperly unbundling the codes.

Confirm implants will be separately reimbursed.

Forward the vendor cut sheets to your coding team as soon as you begin shopping for emerging technology or new implants. Coders are not solely exclusive to your back-end billing process. Involve them early and often. They can crosscheck medical policies on the front end to prevent facility losses.

Require your coders to routinely review carrier guidelines and familiarize themselves with payors’ reimbursement habits.

A seasoned ASC medical coder is familiar with carrier guidelines and payors’ reimbursement habits. Third-party payor expectations are often outlined in your insurance contracts and supplemented by carrier-specific billing manuals. Require your coders to review these often. Using the correct combination of form type and modifiers will mitigate the risk of claim denials. Increase your output of clean claims by giving coders access to these tools early.

Make continuing education a priority.

Certified coders are required to amass a defined number of continuing education credits annually to maintain their certification designation. Support their efforts by routinely enrolling them in courses that bolster their knowledge. Consider allowing them to obtain specialty-specific certification. Continuing education and familiarity with Medicare, Medicaid, and commercial medical policies can increase clean claim submissions and reduce preventable payment lags.

Certified coders are key to ensure clean claims and maximum reimbursement are generated for cases performed at your ASC. Since the ambulatory surgery center is a niche industry, it is important to employ experienced CPCs who are willing to learn the nuances of the ASC billing process. Collaboration between your coders, ASC leadership. and operations team, fosters an efficient claims process that will enhance profitability.

Bethany Bueno – Director of Billing Operations