On the surface, it seems fairly simple. Incorrect codes will result in delayed payment or outright rejection of claims by carriers. Using codes appropriately helps ensure proper payment from third-party carriers and patients.
Appropriate coding also enhances your practice’s relationship with patients. When your office codes claims accurately, patients who file their own claims will have fewer problems obtaining payment from their insurance companies. Yet many major carriers identify the first five areas listed below as the most common coding errors causing delays or inaccurate payments for doctors’ claims. With this in mind, let’s take a closer look at these common problem areas cited by the carriers.
1. Additional code to identify manifestation. At times, it is required to provide an additional diagnosis code in order to provide a complete and accurate diagnosis picture. You may need the one code to describe a condition which is the underlying cause of the manifestation you are treating, and another code for the specific manifestation itself.
An ICD-9-CM tabular notation indicates when the code cannot stand alone and is not to be listed first. Likely companion codes are shown. In the index, the notation is indicated by codes appearing in italicized brackets [xxx.x].
An example of this is when you’re reporting the diagnosis of “diabetic neuropathy” for a patient. You must list the underlying disease code (“250.6x - Diabetes with neurological manifestations”) first and then list “357.2 - Polyneuropathy in diabetes manifestation” as the second code. Remember, you should never report manifestation codes as the patient’s primary diagnosis. You can easily identify these codes since they always appear in italics in ICD-9-CM.
Be Aware Of The Exclude Notes
2. Excludes. This ICD-9-CM notation indicates that any conditions following it are to be coded elsewhere, as indicated in each case. You may find exclude notes at the beginning of a chapter or section, or immediately after any three-digit, four-digit or five-digit code. Such a note following a three-digit code would apply to all four- and five-digit codes within that category. A note following a four-digit code would apply to all five-digit codes within that subcategory.
For example, if a patient presents with marked signs of unsteady walking and incoordination, you cannot code it as “781.2 - abnormality of gait” unless your assessment (and the documentation in the patient’s record) would support a more definitive determination beyond “difficulty in walking” at this time. Without a more definitive finding, ICD-9-CM code 781.2 specifically excludes “difficulty in walking” and directs you to review code “719.7x – difficulty in walking” instead. If you later determine your patient indeed has an ataxic gait, then it would be appropriate to report ICD-9-CM code 781.2 and document it in your patient’s record.
When Specificity Comes Into Play
3. Not Elsewhere Classifiable (NEC). This is appropriate when no code is provided which would permit using a more specific code for the condition, and your patient record contains more information than ICD-9-CM allows you to provide.
4. Not Otherwise Specified (NOS). Using NOS in ICD-9-CM coding refers to a lack of sufficient detail in the patient’s record. Reporting codes in this category will frequently result in denied payments until you can submit more specific information. Be aware that frequent reporting of such nonspecific codes to avoid the burden of looking up specific codes may cause third-party payers to identify your practice’s claims reporting and chart documentation for further review.
When possible, you should not use ICD-9-CM codes containing the terms “unspecified” or “other” (these codes usually have a fourth digit of .8 or .9) if information is available that allows you to use a more specific code. For example, “abscess” lists code 682.9 in the ICD-9-CM Index, yet is followed by almost 200 listings of various types and locations of abscesses. Carriers could perceive the routine reporting of the “682.9 – abscess unspecified site” as indicating that you failed to adequately document the location or type of abscess you were treating.
5. Undercoding. Practices that fail to ensure that the coding information they’re submitting is complete often unknowingly fail to provide the information required to allow fair payment for the services. Just as the routine reporting of the above unspecified abscess code inadvertently would limit carriers’ ability to adequately evaluate the care provided, deliberate undercoding of services such as Evaluation and Management (E/M) codes, due to fear and uncertainty, also continues to cost many practices well-deserved revenue. Greater financial benefits and peace of mind usually come from following current and appropriate coding and documentation guidelines.
Be Involved In The Coding Process
In order to prevent coding mistakes from adversely affecting your reimbursement, there are other important steps you should take.
• Remain actively involved and pursue annual continuing education in documentation and coding responsibilities of your practice. The end of every year brings many changes to the three coding systems, in addition to the latest RBRVS Medicare Fee Schedule updates and CMS regulatory compliance directives, such as HIPAA Patient Privacy, ABNs, E/M documentation guidelines and the current OIG Workplan. So, it is critical you and your administrative staff become well-versed of these changes annually as they impact your practice.
Remember, members of your administrative staff require your support and active participation in order to effectively perform the coding, claims submission and appeals functions required in today’s declining economic environment. Too often, physicians prefer not to be involved directly in claims processing and coding procedures. Unfortunately, such lack of involvement may cost you and your practice a great deal of reimbursement money when unpaid charges must be written off or result in your patients paying for services that should have been paid by their insurance coverage.
There is no one right way for you to document your services, but it is important to strive to record all pertinent information. All coding in your practice should be based on the documentation. Never use codes for levels of service which the patient’s record does not support.
The need for ongoing documentation and coding training for you and your staff cannot be over-emphasized. Encourage staff members to bring questions to you and your administrator.
Do What You Can To Ensure Clarity
With Each Carrier
• Clarify and identify carrier policy and procedure
coding/reporting requirements that are applicable for each of the major carriers in your payer mix. Patients generally do not understand how their insurance plans work and especially are not aware of the consequences that can occur if your practice does “not play by the rules.” However, be aware that it can be at your expense if a patient requests and receives services that will not be paid. Also be mindful that patients also unfairly expect their doctors’ practices to be able to assist them in adhering to their insurance coverage requirements.
Managed care contract physician responsibilities have created incredible mounds of paperwork for the practices. Further, there has been a noted lack of uniformity regarding reporting, referral and follow-up services requirements among various carriers.
For example, some third party and MCOs provide specific instructions for completing items on the HCFA-1500 claim forms in their participating provider manuals. When there are no carrier-specific requirements, the element should be completed according to the requirements on the form. It is in your best interest to understand how the plans expect you to report services. Fee increases may be based on information provided by your practice, so make sure that it is correct and accurate.
Stay On Top Of The Fee Schedule Changes
• Respond promptly to MCO correspondence. Several times each year, many of the major MCOs will send new fee schedules or fee schedule addendums to their participating physicians. You may have less than a week to either accept or reject these changes. A new fee schedule may offer more favorable reimbursement for certain procedures, but it may decrease the reimbursement rate for a particular procedure which is commonly performed in some offices. If such a fee schedule remains unopened on your desk, you may have missed the opportunity to reject that fee schedule and will therefore receive a less favorable reimbursement rate.
It is important for all correspondence regarding contract agreement modifications and updates to be brought to your attention as soon as possible. Have your business staff prepare a comprehensive analysis for your review prior to your response deadline so you can make the appropriate informed decisions for your practice.
Accurate utilization rates for all services provided are also necessary to evaluate the financial viability of your contracts with the various plans. Financial viability means your practice can provide all the necessary services to its members within the financial parameters defined by the contract while generating income for the practice. Financial viability depends on a number of factors, including the type and volume of services provided, the costs involved in providing services and the reimbursement provided.
Build And Maintain Relationships With The Carriers
• Establish relationships with the various provider relations personnel at insurance companies (MCOs, Medicare, Medicaid, and all major carriers with which your practice is affiliated). In addition to your administrative staff needing to be well trained in the rules and expectations of each payer your practice deals with, it is also important to develop a relationship with your major carrier provider relations representatives. Someone from your office should attend all meetings they offer. Maintain positive, ongoing contact with your carriers in every way you can.
Utilize the personnel available to you from the third-party payers to help clarify the details of your participation with them. Provider representatives definitely can assist you in resolving problems as they arise between your practice and the plans.
Given the importance of thoroughly documenting the dates of claim submission and all follow-up activities with a carrier, always get the names of the people with whom you communicate and be sure to note any action promised to you. This paper trail is essential in situations that cannot be resolved favorably without state insurance department or legal intervention.
Why Monitoring EOBs Is Essential
• Monitor and audit EOBs and address inappropriate claims reductions/denials quickly. The explanation of benefits (EOB) statement accompanies the check from the insurance company and explains the process for determining a payment issued by the insurer. A surprisingly high number of claims are not paid correctly, so although monitoring EOB claims payments requires discipline and organization, it very often proves to be financially rewarding to podiatric practices.
Knowing the status of individual claims is the starting point to initiating any appeal. It is important to determine whether an appeal is appropriate and worthwhile. Medicare requires appeals of underpaid claims to be filed within six months of receipt of the explanation of medical benefits. Many of the commercial carriers’ contracts contain similar or even shorter timeline limitations, so it is crucial for you and your administrative leaders to address this potentially lost revenue quickly.
When Should You Appeal?
Keep in mind that appealed claims have a 90 to 95 percent success rate in payments being approved on previously denied or underpaid claims. In order to be successful in this endeavor, you need to ensure that a qualified staff person (with adequate training) carefully reviews EOBs promptly and regularly so he or she can identify problem claims.
Have your staff review any claims paid at less than 75 percent of the payment amount you anticipated. As the process becomes more established, have the reviewer add higher-paid claims to the review. Comparing claims against EOBs also helps identify situations where the carrier’s staff entered the wrong info and situations where carriers are rebundling codes and paying under a single code number.
Sometimes your staffer will find a coding error or a carrier entry error and a “corrected” claim can be submitted. Failure to “link” ICD-9-CM diagnosis code(s) with the CPT procedural code(s), and failure to support the need for a service with the adequate ICD-9-CM code(s), causes many of these problems. Claims may also be denied if the service falls within a global surgical “package.” These appeals usually are successful if the documentation clearly supports an unrelated problem or points to an underlying condition not considered part of normal recovery, which has been indicated by the application of the appropriate modifiers.
Whether you should appeal a denied claim depends on the reason for denial. You should only appeal or resubmit claims when you have reason to believe the earlier claim was not processed appropriately. Documentation for reconsideration appeals may include operative and other reports and copies of published material supporting the need for the treatment provided.
Keep in mind that an operative report alone for appealed claims will not usually result in a higher payment unless there was a coding or entry error in the original submission. At the least, you must include a letter of explanation, advising reviewers of the points you feel need attention or reconsideration, with the appeal request.
Although you may not personally sign the insurance form, it is well established that physicians are legally responsible for the actions of their employees and agents, such as billing services. A lack of understanding of coding guidelines does not exempt you from liability for billing errors. This level of liability has brought coding and medical record documentation to the forefront and creates an environment that mandates your close involvement and expertise in this critical area of your practice.
Ms. Bradford is the Director of the Department of Socioeconomics and Practice Management for the American College of Foot and Ankle Surgeons (ACFAS). She will be presenting sessions on “Making Sense of HIPAA” and “ICD-9-CM Coding for Compliance and Reimbursement” during the upcoming ACFAS Two-Day Practice Management Seminars on Feb.25 and 26 in Beverly Hills, Calif. She will also be giving these presentations on March 5 and 6 in Chicago.
For additional information, you may contact Ms. Bradford at (847) 292-2237, ext. 322, or send an e-mail to firstname.lastname@example.org.