By Julie Bos, CPC
I have experienced all types of office settings, from very large billing services to a one-physician practice, and the same problems confront them all. It’s always the easy money—the low-hanging fruit—that gets attention, while the rest seems to be left to rot on the tree. I believe that a provider deserves to receive appropriate compensation for all services rendered. In the following true story, you will see how knowledge of the appeals process yielded a large amount of money that otherwise would have gone unnoticed and unpaid.
Let the “Appealing” Truth Be Told
In mid-2012, a behavioral health provider contacted me because they were being audited by their state Medicaid agency. The state agency told them that having a CPC® on their team would lend credibility to their billing.
After an internal audit, during which I found and corrected coding and billing errors, I noticed that the state behavioral health Medicaid payer was denying full reimbursement on home-based code H0004. The clinicians would typically spend 2-3 hours at the client’s home, but were being paid for only one hour. Per the coding guidelines in the Uniform Services Coding Standards Manual (USCSM), H0004 should be billed in 15-minute increments, with a minimum of 8 minutes and no maximum.
I questioned the office staff and administrator why they hadn’t been paid for the extra hours. They explained that when the behavioral health Medicaid payer was initially contacted, they were told “plan provisions” determined that only one hour was payable. Being timid to question a state agency further—especially during the middle of an audit—they gave up.
If It Doesn’t Sit Right, Research and Appeal
After the auditing issues were corrected, and a new plan for coding and billing was established, I turned my attention to the problem with Medicaid. The state agency’s answer still did not seem right. I researched the USCSM and the related website and found nothing to support their denial of H0004 claims beyond one hour. I started appealing for additional payment.
An appeal is simply a request stating that you don’t think a payment or denial decision is valid based on information you have available to you, and is submitted with the explanation and supporting documentation you used to determine this.
Included in the appeal was the documentation gathered from the state Medicaid agency manual and website showing where I thought the code should be paid for the full time spent with the client. I also sent records documenting the service and time spent with the client, and a cover letter clearly explaining my reason for requesting additional payment.
In return, I received denials. The denials stated that the claim was paid according to “the plan provisions,” and included the names of two top-level executives who reviewed the appeal(s). I again looked through the “plan provisions” information in the USCM and its website. I also reviewed the information given in the patient plan.
If It Isn’t in Writing, Don’t Take No for an Answer
Once again, I couldn’t find anything in either the provider manual or the patient plan to justify their denial. I started making calls. I called the claims department. The customer service representative told me the payment decision was upheld because of “plan provisions.”
“OK,” I said, “Please show me where it says there is a time limit on this code.” I explained that I didn’t want to waste my time, or theirs, on a mistaken appeal, but that I couldn’t find anything showing a limit for H0004.
My question was initially met by silence. Then, I learned the customer service representative could only access the information showing in the computer, and had no real knowledge of why and how claims get paid or denied. She could not help me.
I asked to speak with a supervisor. I gave the name and credentials of the executives from the denial letter, which stated they had reviewed the claim, and if there were any problems to call them. This request also resulted in silence. I again explained the situation, and asked the supervisor to get me in touch with someone who could direct me to the place showing the limit for H0004.
I was finally transferred to the voice mail of one of the executives named in the denial letter. I requested for him to get back to me with documentation supporting the denial decision. He returned my call and said that he was unable to give me the backup for this denial, but he would see what he could find.
I never heard from him again, so I started second-level appeals.
Stand Your Ground
A second level appeal is used when the initial appeal has been upheld (as in this case), but you still disagree with the results. There should be solid evidence to support and justify the time and effort necessary for this type of appeal. In this case, there was solid lack of evidence on the part of the agency, as they could not provide me with documentation supporting their case.
I sent 24 pages of documentation for each claim—from the payer’s own manual and website, for both provider and patient—defending my position that there was no time limit for the code in question. I requested that the payer prove its position and provide documentation.
In the meantime, I received a phone message from the local provider representative stating that the issue was being reviewed, but the system was “broken.” To me, this was a serious problem. How long had this been going on? Insurance agencies are quick to let the provider know when he or she is not compliant. Providers need to hold insurance agencies to the same standard.
A few weeks later, checks started to arrive. The state Medicaid agency had realized its error and began reprocessing claims from Jan. 1 forward. To date, this one appeal has produced over $11,000 in revenue for this one provider. And this is only for claims January through March.
What excites me is that not just one provider will benefit from my appeals. A problem was identified, questioned, and shown to be in error, and now the state agency must review their entire claims processing for this code on all claims paid incorrectly. Whether the agency will reprocess and pay out additional money automatically, or wait for individual offices to send appeals, is unknown. If the agency does the correct thing and automatically processes previously denied claims, many providers will receive additional revenue because I took a stand.
Knowledge + Diligence = Money
Due to my client’s lack of knowledge, they gave up. They were intimidated by the ongoing audit and the prestige of a government agency. One knowledgeable person with a firm grasp on the appeals process managed to net tremendous revenue that would’ve otherwise gone uncollected. My value to this one entity has grown tremendously.
By persevering in the appeals process, you make yourself a more valuable asset to your employer. More value equals increased earnings.
Lessons to be learned:
- Know the appeals process.
- Provide supporting documentation.
- Don’t give up if you know you are right.
Julie Bos, CPC, earned her CPC® certification in 1994 and spent the next 19 years in multiple specialties perfecting her medical billing and appeals skills. As owner of her own revenue management business based in Denver, Colo., she works at attaining the maximum revenue for her clients.
April 1st, 2013
By Barbara J. Cobuzzi, MBA, CPC, CPC-H, CPC-P, CPC-I, CHCC, CENTC
Many practices enjoy the benefits of outsourcing their billing functions, such as the ability to concentrate on providing patient care. Choose the wrong billing company, however, and you may end up with even greater distractions and financial frustration.
Meet Your Billing Needs
To be sure you choose a billing company that meets your needs efficiently—and does so compliantly—do some homework to answer the questions below:
Q. What credentials/experience does the billing service have?
Find out how long the billing company has been in business and what sort of reputation they have. You’ll also want to know if they are registered or licensed by the state they are in (if their state requires it), and if they carry professional liability insurance. Ask if they provide a written contract for their services spelling out each party’s responsibilities in the business relationship. And don’t be afraid to ask how many clients they have, and if they have any clients similar in size and patient mix to your practice. Get references, too, so you can contact current and previous clients and ask for their opinions of the service’s performance.
Q. Does the billing company have experience in your specialty?
The billing company should understand the unique factors affecting your specialty; and they should have an appreciation for the issues surrounding your coding, reimbursement, denials, and appeals. If not, ask if they have the resources to get up to speed, to your satisfaction, so your revenue does not suffer.
Q. What kind of training does the staff have and receive?
Find out if the billing service’s management hold certification from a professional billing organization, and if there are billers and professionally certified coders on staff. If so, dig deeper to find out if the service provides ongoing education and guidance for these employees.
You have a right to know this information, as well as what resources the biller provides for its staff. Code books (CPT®, HCPCS Level II, etc.) should be up-to-date. The service also should have a written compliance plan. If it does (and you need to be sure), ask if you can you review the plan. Speaking of compliance …
Q. What is the procedure to protect the privacy of information?
Inquire into whether the service has a compliance officer, or someone who ensures the billing company provides secure (encrypted) email communications consistent with Health Insurance Portability and Accountability Act (HIPAA) requirements. You also should be aware of whether the billing company uses home-based employees and, if so, what precautions are taken to ensure HIPAA compliance.
Q. What are the company’s technical capabilities?
Do they electronically process and submit claims, either directly to Medicare or through a clearinghouse? Ask how often claims are submitted to the clearinghouse; what the process is for third-party payers; and if they use batch controls to minimize data entry and other errors. Make sure you know if the service will help your practice with forms, superbill design, office processes, etc.
Q. How does the biller handle claim changes?
Learn what the service’s protocol is for changing CPT® or ICD-9-CM codes if errors are discovered. What’s the protocol for missing information?
Q. What type of financial reporting does the billing company provide?
For instance, can the practice request ad-hoc reports? Ask whether the service can provide reports to determine physician compensation levels. If the practice is capitated, can the billing service report on capitated service utilization? Also inquire into whether your practice can access billing data at its office; and ask to see samples of their month-end reports to find out how robust they are.
Q. How is the billing company’s follow-up practices?
Specifically, how successful are they with appeals? Ask what parameters they use to determine if they will appeal a denial or underpayment. Find out the kind of accounts receivable (A/R) follow-up procedures they have. And ask how often the service follows up on payer accounts.
Q. How much will everything cost?
If the billing company’s fee is based on a percentage, find out if it is a percentage of charges, or a percentage of receipts (the latter is better). Also find out how refunds are handled. Are they netted out of receipts, so your practice is not paying the billing company for money returned to the payer? And don’t forget to ask if the billing service charges a start-up fee.
If the answers to any of these are not to your satisfaction, keep looking until you find a billing service that meets your expectations.
Remember: Even though you are outsourcing, the practice is ultimately responsible for its own claims. You need a billing company you can trust.
Experienced Staff Is Crucial
Even if the billing company is not coding for you, it’s a good idea for them to have at least one certified coder on staff. Appeals require the knowledge of a coder, and compliance also demands the increased knowledge that a certified coder can bring to the table. Even the billers need to know aspects of coding to do an excellent job in billing for your practice. Key areas of education include rules and regulations, where to find the information for Medicare, Medicaid, your private payers, modifiers, correct order of diagnoses, bundling and National Correct Coding Initiative (NCCI) edits, what separate procedures are, etc. You do not want a billing company that is just providing data entry.
Find a billing company with experience in your specialty, with a proven track record in compliantly optimizing practice revenue. I would not recommend entering into a billing company relationship without a written contract that very explicitly spells out each party’s responsibility.
Compliance is no longer an option. The Patient Protection and Affordable Care Act (ACA) mandates a compliance plan for all practices, with minimum requirements to be spelled out by the Office of Inspector General (OIG). A practice cannot afford to contract with a billing company that does not have a living, breathing, and operating compliance plan in place.
Check out the billing company’s recommendations. Talk to both current and past clients, if possible. Find out what the benefits of working with the billing company are, and what’s required of you to make the relationship function flawlessly. Clients should be able to confirm what the company has told you during the sales phase of your relationship.
Finally, do not expect to see your full income generated by the billing company for approximately four months. It takes about that long for them to get a full queue of your billing into the payers and a revenue stream to start flowing into the practice. Make sure you keep collecting on the A/R that was in process when you contracted with the billing company to keep the bank account healthy during this initial period.
Barbara J. Cobuzzi, MBA, CPC, CENTC, CPC-H, CPC-P, CPC-I, CHCC, is president of CRN Healthcare Solutions and senior coder and auditor for The Coding Network. She is consulting editor for Otolaryngology Coding Alert and has spoken, taught, and consulted widely on coding, reimbursement, compliance, and health care-related topics nationally.
November 1st, 2012
2012’s bundling of procedures and assigning of “experimental” T codes can hamper provider reimbursement.
By Barbara Cataletto, MBA, CPC
Changes to CPT® 2012 spinal codes and coding guidelines have an important impact on reimbursement, new technologies, and the advancement of patient care. Let’s review the changes you’ll need to know to properly document and code these surgical cases.
63030 Not for Minimally Invasive Lumbar Decompressions
Compared to 2011, you’ll notice a discreet difference in the coding requirements for decompressions of the spine. Discectomy, hemilaminectomy, and interspace decompression now require greater detail about the surgical approach.
For example, 63030 Laminotomy (hemilaminectomy), with decompression of nerve root(s), including partial facetectomy, foraminotomy and/or excision of herniated intervertebral disc; 1 interspace, lumbar now describes an “open” procedure only (as does 63020 Laminotomy (hemilaminectomy), with decompression of nerve root(s), including partial facetectomy, foraminotomy and/or excision of herniated intervertebral disc; 1 interspace, cervical). You may no longer report 63030 for minimally invasive (i.e., endoscopically assisted) lumbar procedures, as in previous years. Instead, 62287 and 0275T now cover percutaneous and endoscopic approaches:
- 62287 Decompression procedure, percutaneous, of nucleus pulposus of intervertebral disc, any method utilizing needle based technique to remove disc material under fluoroscopic imaging or other form of indirect visualization, with the use of an endoscope, with discography and/or epidural injection(s) at the treated level(s), when performed, single or multiple levels, lumbar
- 0275T Percutaneous laminotomy/laminectomy (intralaminar approach) for decompression of neural elements, (with or without ligamentous resection, discectomy, facetectomy and/or foraminotomy) any method under indirect image guidance (eg, fluoroscopic, CT), with or without the use of an endoscope, single or multiple levels, unilateral or bilateral; lumbar
Note that 62287 and 0275T bundle (include) many related procedures, such as fluoroscopy, imaging, discogram, etc. The bundled services may not be coded separately. The codes also describe procedures performed at either single or multiple levels; 0275T further describes either unilateral or bilateral procedures.
When selecting among 63030, 62287, and 0275T, you must review documentation language carefully to differentiate the approach and find the specific terminology necessary to support the chosen code. Look for terms such as “percutaneous,” “cannula,” “fluoroscopy,” “tubular,” “intralaminar,” “port incision,” and “endoscopic” to identify decompression by minimally invasive technique as described by 0275T and 62287. Further clarification is required to determine a needle-based approach (62287) versus a non-needle-based approach (0275T). The language here is very specific.
Minimally Invasive Fusion Now a Category III Procedure
Descriptors for 22610 Arthrodesis, posterior or posterolateral technique, single level; thoracic (with lateral transverse technique, when performed) and 22612 Arthrodesis, posterior or posterolateral technique, single level; lumbar (with lateral transverse technique, when performed) have been revised (removing “without”) for 2012 to require that fusion include a transverse technique. This is another critical change. To report a minimally invasive approach, the coder must now look to Category III codes:
0220T Placement of a posterior intrafacet implant(s), unilateral or bilateral, including imaging and placement of bone graft(s) or synthetic device(s), single level; thoracic
+0222T each additional vertebral segment (List separately in addition to code for primary procedure)
As evidenced by the code descriptors, 0220T-0222T include fusion as well as instrumentation, grafting, etc. Prior to this year, these procedures have been coded separately in addition to 22610 and 22612; in 2012, the new codes cover everything.
Understand the T code Challenge
Category III CPT® codes, also called temporary codes or T codes, represent emerging medical technologies that have not yet been approved by the U.S. Food and Drug Administration (FDA). Unfortunately, payers often don’t acknowledge T codes as a viable code set, claiming that the procedures are experimental and not covered. To make matters worse, T codes are not assigned relative value units (RVUs). The lack of RVUs is significant because it signals to payers that a procedure or service is experimental, unconventional, and/or an unacceptable medical treatment. This could mean that effective procedures and services assigned T code status never “catch on,” due to a lack of reimbursement.
As an example, there are difficulties using T codes for pre-authorization, submission, and payment for services going back to the development and implementation of artificial spinal disc surgery. The artificial disc coding and reimbursement example amply illustrates how T code status has nearly destroyed the artificial disc procedure as an adjunct procedure to the spine surgeons’ repertoire.
In 2005, practices using unspecified procedure codes to report artificial disc procedures began using new Category III codes 0090T-0092T (total disc arthroplasty). Payers began treating these procedures as experimental. Years later, even now that CPT® directs coders to use 22856 (cervical) and 22857 (lumbar) to report artificial discs, many payers refuse to yield and pay for the procedures—for the most part due to past medical determinations.
In reviewing the 2012 CPT® changes, we see that several established spinal procedures have now been transferred to T codes. As mentioned, these include endoscopic discectomy (lumbar, 0275T; as well as 0274T Percutaneous laminotomy/laminectomy (intralaminar approach) for decompression of neural elements, (with or without ligamentous resection, discectomy, facetectomy and/or foraminotomy) any method under indirect image guidance (eg, fluoroscopic, CT), with or without the use of an endoscope, single or multiple levels, unilateral or bilateral; cervical or thoracic) and facet fusion (thoracic and lumber, 0220T-0222T; as well as 0219T Placement of a posterior intrafacet implant(s), unilateral or bilateral, including imaging and placement of bone graft(s) or synthetic device(s), single level; cervical). Both endoscopic discectomy and facet fusion are widely accepted surgical procedures, with a significant history of success within the spine community. Surgeons performing these minimally invasive procedures (and facilities offering them) will likely feel a significant economic crunch with the shift from the traditional CPT® Category I code submission to T code submission.
Some payers understand the difficulties posed by T codes and have responded by providing coverage and reimbursement advisories on their websites, or may engage in “pre-surgical” discussions regarding coverage and reimbursement. Whenever there’s doubt, it’s best to be proactive and communicate directly with your payer representatives.
Proactive and cooperative communications will reduce post-surgical denials. Physicians will play a key role in educating and encouraging carriers to approve procedures if they can communicate effectively about the medical benefits to the patient.
Don’t Give Up Reimbursement without a Fight
Practices and facilities will be required in 2012 to reauthorize any previously authorized procedures that are now reported with a T code. Practices that do not confirm authorization may find themselves—as they have in the past with the artificial disc procedures—receiving denials for what are suddenly considered to be experimental or noncovered procedures.
Setting the standard for reimbursement if preauthorization is granted is a secondary challenge. Even with preauthorization and proven reimbursement history for endoscopic discectomy and minimally invasive facet fusion, the practice or facility will face challenges. T codes generally result in an immediate denial, regardless of approval status, and require in-depth appeals and audits on a regular basis. The ability to navigate these challenges requires continued communication via the appeals process. Practices will be forced to provide supportive documentation of the preauthorization, previous payment history for similar procedures, and a “stick to it” attitude toward an acceptable reimbursement solution.
One of the best defenses is a great offense. When dealing with T codes, pursue payer authorization in writing, inclusive of the CPT® codes and the patient’s diagnosis and name, specific to the individual case. This basic document is often considered unnecessary until the denial is received, and getting it up front will save a great deal of effort.
Fortunately, in the case of endoscopic discectomy and/or minimally invasive facet fusion, a practice or facility may look to historic payments from codes 63030, 22610, and 22612 to support the reimbursement levels they expect for the T codes that now apply. Review practice reporting to identify payment trends (both highs and lows) to develop an acceptable fee range for these procedures in your geographic area. This will be helpful in formulating and supporting reimbursement appeals.
Industry is not likely to embrace technologies if surgeons, unsure of reimbursement, are hesitant to perform new procedures. This may hurt patients the most. Developing technologies should involve open discussions about medical necessity, CPT® applications, and reimbursement issues during the research and development phase to reduce the possibility of undesirable or unacceptable coding and reimbursement results. Sharing in new developments requires commitments from industry, physicians, patients, and insurers if we are to continue the process of improved medical treatments and medical successes.
Barbara Cataletto, MBA, CPC, is CEO of Business Dynamics LLC and the founder and CEO of CaseCoder™.
April 1st, 2012