ANSWERS TO YOUR BILLING, CODING QUESTIONS: SPRING 2008

By Elizabeth W. Woodcock, MBA, FACMPE, CPC

Gaining a handle on unpredictable coding and compliance issues is vital to a healthy bottom line, not to mention both employee and patient satisfaction. Without the right tools and processes in place to manage through these constant changes, a practice’s cash flow, and standing with both patient and employees, can quickly deteriorate. Here is a look at some of the common questions practices face, along with answers that will help keep you on the right side of payer policies and, ultimately, optimize reimbursement.

QUESTION: The surgeon for whom I bill performs surgery with another surgeon. I attach the modifier -62 to the procedure codes, but I get denials back on most of them. What am I doing wrong?

ANSWER: If your surgeon performs a co-surgery, you are coding the services correctly. -62 is the modifier you want to use. However, for reimbursement to be accurate, you and the other surgeon’s office must both be submitting the same procedure code with modifier -62. Most co-surgeries require that the diagnosis codes to be the same as well. Unless this was a one-time occurrence, contact the biller for the other surgeon, and ask to meet to review coding and reimbursement for the services your physicians perform together. Even with correct coding, it’s not uncommon for surgeries performed by two surgeons to be pended for medical review. In these cases – or in the event of a denial – be prepared to submit an appeal for payment with documentation to support your case.

QUESTION: My biller told me that our Medicare carrier is denying claims. She thinks that it may be due to a problem with my NPI. Is there anyway to check on this?

ANSWER: National Provider Identifications (NPI) became effective in May 2007. The program, however, is still working out some bugs and the NPIs are not always correct. Go on the Web, and check the individual and institutional (if applicable) NPI associated with your practice here. At a minimum, verify the name, address and taxonomy code (e.g., your specialty). Note that the address on display is publicly available. If you have registered your home address, you may want to consider changing it to your business address and/or a post office box for this purpose. If you do find an error, go to the National Plan and Provider Enumeration System (NPPES) Web site, and follow the links to download an update form.

QUESTION: I submitted a claim for a G0107 (fecal-occult blood test or FOBT) last month and it was rejected.  What’s the problem?

ANSWER: Medicare retired the code G0107 on January 1, 2007.  Instead, use 82270 to bill a FOBT.

QUESTION: Although it’s never happened to me, I’ve read a lot about employee embezzlement. What can I do to protect my practice?

ANSWER: Check all applicants’ references thoroughly, and perform background checks and drug testing. Establish internal controls (such as dividing the tasks of posting charges and payments between two people), particularly where cash is involved. Watch for employees who refuse to take vacations or won’t allow anyone else to be cross-trained in their jobs. Savvy con artists can embezzle regardless of the policies in place, so be sure to have fidelity bonds on all employees. In the event of embezzlement, the bond will pay back your losses – and the insurance company will chase the embezzler for repayment. Most importantly, don’t let an embezzler get away when you discover a problem. File charges to get it on the public record. Too many of these thieves are able to specialize in medical practices because they know that the victims (you or colleagues) show too much mercy.

QUESTION: Another practice in our community is being called a “rural health clinic.” What is that, and where can I find out more?

ANSWER: Rural health clinics (RHCs) are designated by the Department of Health and Human Services (HHS) and identify practices meeting certain criteria about structure (e.g., must have a nonphysician provider and must perform certain basic laboratory tests as required by the HHS), and geographic location (e.g., must be in a designated rural health professional shortage area or HPSA). Rural health clinics enjoy an all-inclusive, cost-based encounter rate for services provided to Medicare and Medicaid patients.  Although it varies, RHCs typically receive more revenue per encounter than private practices.  For more information about RHCs click here.

Elizabeth Woodcock is the founder and principal of Woodcock & Associates, with 15 years experience in medical group operations and revenue cycle management. A speaker, trainer and author, Ms. Woodcock has led educational sessions for the Medical Group Management Association, the American College of Obstetricians & Gynecologists and the American Medical Association, and has consulted for clients as diverse as a solo orthopedic surgeon in rural Georgia to The Mayo Clinic. She is author of Mastering Patient Flow to Increase Efficiency and Earnings, and co-author of The Physician Billing Process: Avoiding Potholes in the Road to Getting Paid and Operating Policies and Procedures Manual for Medical Practices.

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