BETTER CODING: Make What You Earn

Lots of practices miss revenue thanks to sloppy coding. And we’re not talking about losing pennies. Annette Grady, an auditor, says she routinely finds mistakes that add up to anywhere from $15,000 to $30,000 in lost revenue from a standard review of just 15 charts from a surgical practice. Grady is a healthcare advisor for Eide Bailly in Phoenix and an officer for the American Academy of Professional Coder’s (AAPC) National Advisory Board.

Luckily, a few tips can help you find what’s gone astray.

Physicians Practice interviewed people who make a living auditing charts and billing records to find missing money and asked what common mistakes they see. Here’s their list of top mistakes. Work on these - and start getting paid more.

It’s a Superbill, Not a Perfect Bill

Don’t rely on your superbill or charge ticket - the document with a list of codes on it you use to show the billing staff what you did. It’s probably incomplete or includes old codes and useless code descriptions.

“What I’ve run into recently is where the charge ticket or superbill did not have all of the codes, and had codes that weren’t appropriate, so the physicians weren’t marking services that they did,” says Lisa Souba with LAS Practice Management and Coding Services in Breckenridge, Colo. If it’s not on your list of options, it just never gets noted.

For example, Souba worked with an urgent care facility near her mountain home. While she was there, a patient staggered in, suffering from altitude sickness, not an uncommon occurrence for this clinic. Physicians spent considerable time with her, running an IV for hydration, among other things. When Souba checked the billing afterwards, she found the IV wasn’t even mentioned, though the practice could have billed for both its supplies and services.

Why was it missed? IVs weren’t on the practice’s superbill.

Similarly, Souba visited a practice that included only a single code for lesion excision on its superbill, even though are dozens of appropriate codes, including those reflecting whether a lesion is benign or malignant, its size, location, and the number of lesions removed. Undoubtedly, physicians at that practice were losing money every time they circled that one little code instead of understanding the full breadth of options.

Superbills are specifically designed to reflect the most common services and procedures for any given office. You can’t carry around an entire CPT book, after all, so an edited version is necessary. Just realize that your charge ticket reflects the 80 percent of things you do over and over. “You get in your own little world of what you code all the time. So many things are missed,” says Grady. The other 20 percent of the time, your best bet is to write in anything extra or unusual you do. If you can get paid for it, your billing staff should know and can amend the superbill over time.

“A lot of it really comes down to communication and having that physician have someone to go to say, ‘Hey, I did this. Can I bill for it?’” advises Souba. “It’s sitting down and knowing what your physicians are doing.”

It also helps to educate staff about coding, including nurses. “The [nurse] is the one who is in the room with the physician,” Souba points out. If a nurse has to prepare a lab requisition for something biopsied, she should help make sure the biopsy is noted on the superbill.

Billing staff, too, may need more education than they currently get. When Souba worked in private practice, she trained all billers and data entry staff on coding issues common to their specialty. That meant they had the smarts and authority to catch disconnects between diagnosis codes and procedure codes.

For example, in obstetric practices, staff can be trained to look for diagnoses such as sinusitis or hypertension paired with a CPT code for routine care included in the global.

“These are key indicators on the charge ticket that say we can bill separately. These indications fall outside of your normal, global antepartum visit” and treatment can be billed separately, Souba points out.

Similarly, if a primary care physician codes an office visit but the diagnosis coding mentions a lesion, a good data-entry person will ask whether the physician removed the lesion and can charge for that procedure as well.

In Souba’s practice, billers were encouraged to stop and consult with the physician instead of just mindlessly copying what was circled on the charge ticket.

“Open up the dialogue for proper coding,” Souba says. “Not all data entry people are trained to think” critically about what they are doing, she says, but education can go a long way to changing that - and finding lost revenue.

Other tricks for identifying missing dollars? Tap into your practice management software and run a report of your top 100 procedure codes. What things just seem to appear too often, given your experience? What things don’t appear at all? It might be constructive to compare the report to external samples, such as those provided by the Medical Group Management Association’s Coding Profile Sourcebook.

Alternatively, call in an auditor with experience in your specialty and ask for a prospective review of your documentation and billing - that is, review it all before you send it out to be paid. That way, you can correct any mistakes before they really matter from a compliance or financial perspective. The auditor’s fees could easily be covered by recaptured revenue.

Keep in mind, too, that CPT and ICD-9 codes change every year. Update your superbill annually, before January 1. It’s relatively easy to do so. Most annual CPT guidebooks indicate which codes have changed and some even offer an index of codes that have been deleted and added.

Beware of Add-Ons

When reviewing your superbill, pay particular attention to how add-on codes are listed and described. Add-on codes refer to procedures commonly carried out along with a more primary procedure. They are separately billable.

The classic example is from dermatology, where CPT 17000 bills for destruction of a benign or premalignant lesion - just the first one. If the physician removes more than one, she then also codes 17003 for each and every other lesion, two through 14 - that’s the add-on code.

But Betty Johnson, president and CEO of CPC Solutions, a Chicago-based healthcare consulting firm, and officer on the board of AAPC, met a dermatologist making a very typical mistake.

“The dermatologist sometimes would work from 7 in the morning until 10 at night, but the practice he was working for told him he was losing money. He said that just couldn’t be” and engaged Johnson to find out what was going wrong. She quickly discovered that he would code the add-on code 17003 just once whether he was working on the second lesion or the 14th.

“They were billing out one add-on code at about $50, when in fact, he had done much more work,” Johnson says. “That was a lot of money that was just being left on the table, one because of how the superbill was set up [she thinks the description misled the dermatologist] and two, because the physician just didn’t understand the coding.”
Make sure you know which codes on your superbill are add-ons and how you are supposed to use them.

Know Your Modifiers

“There are classes everyday somewhere on [modifiers] and it still seems to be an issue,” says Johnson. Here is a run down of the major troublemakers:

-51, multiple procedures. Use this modifier “when, at one session, multiple procedures are done at the same area of interest,” says Johnson. “For example, you do an upper GI endoscopy, and you take some biopsies and take a polyp by snare - or a lesion removal and a layered repair at the same site.” Using the -51 signals the payer to reduce payments for secondary and tertiary procedures. Only the first code is paid in full. For this reason, remember to try to code procedures in order, from the most valuable to the least. And don’t reduce the amount you charge, says Grady. Most payers automatically apply a reduction to the services with a -51 modifier. If you’ve already cut your price, you’ll just end up taking that discount twice.

-59, distinct procedural service. The -59 “says I did something distinctly different at either a different site at the same session or at a separate session,” explains Johnson. Say, for example, you remove a lesion from a patient’s right arm and left leg at one visit. You’ll want to signal to the payer that these were quite separate procedures, each complete in and of itself, so you’d use the -59 modifier. You should never use the -51 and the -59 modifier on the same code. It doesn’t make sense. The former indicates that the procedures were part of the same basic process; the latter, that they were separate.

-25, significant, separately identifiable E&M service performed by the same physician on the same day of another procedure or service. Ah, the dreaded modifier –25 - the bane of many an office. Physicians should be able to get paid for performing an extra procedure, such as removing impacted earwax or performing an EKG when the patient complains of an irregular heartbeat, during a routine office visit. That’s common sense, and it’s consistent with the American Medical Association’s CPT guidelines. You indicate to the payer that it is a separate service by adding the -25 modifier to the E&M visit.

In reality, however, many, many payers routinely deny claims that include the -25 modifier. “Part of the problem is that the rules the AMA sets when publishing CPT guidelines don’t always agree with payers’ rules on modifiers. Physicians don’t get it or just feel like they will never get paid so they just don’t bill it,” says Johnson.

She urges physicians to fight for the correct interpretation of the rules instead of just writing off the denials or not coding -25 at all. “If it is valid for you to get the reimbursement, if you have done that separate service, you should code and bill for it. And if you get denied, you should appeal it. … You have to go after it.”

Instead, she sees too many physicians who simply don’t code the E&M at all if they also provide some other service. “When physician offices are doing services in the office - like an EKG - it’s not that they are under-coding the E&M service, it’s that they are not coding them at all. In the cases where they have an E&M service that leads to an EKG, they should and can get reimbursed for both,” she maintains.

Grady agrees. “Whose rules do you follow? There are so many other interpretations of the rules…it’s a constant struggle between correct coding and getting paid. … Do you change your claims for every payer? With larger facilities, that’s hard to manage. I always recommend, code what you do and let the payer take the reductions.”
If payer has a written policy that it won’t pay for this particular combination of codes, then don’t appeal. If it’s not in writing, do appeal, she says.

“The single biggest way I see where physicians lose money in coding is to provide two distinct services and only ask for payment for one of them,” concurs Bill Dacey, principal in The Dacey Group, a coding, documentation, and compliance consulting firm in Stanley, NC, and another AAPC officer. But, unlike Grady and Johnson, he thinks physicians should stop trying to handle the problem with coding alone.

“The tide is going out on paying physicians for other little incidental things they do,” he says. Many services can be considered “incidental” to the office visit. “Given that third-party payers can bundle or exclude certain services, that leaves physicians in a position where they have to decide what to do,” Dacey said. They can postpone other services for a visit scheduled on another day or they can perform the extra service only if the patient agrees to pay for it, he suggests.

“The smartest thing would be to divide and conquer there, to not do two things on the same day. But any doctor will tell you it’s not so easy to do.”

Patients often have valid reasons for not wanting to make a separate appointment. It can be hard to arrange time off from work, transportation, childcare, and a million other things. At that point, says Dacey, “if you are going to expect to get paid for more than one thing at a time, you are going to have to get that extra payment from the patient, not from the insurance company.”

Some insurers and plans will be fine with that, he insists. Others won’t.

“This can be a real sticky wicket. These types of services are often both covered services. It’s just that some policies won’t pay for them together.” To know for sure whether the patient can be charged, physicians have to take a close look at each and every contract in their office. “Physicians desperately want there to be one answer, but there isn’t one. It’s very poorly managed.”

It may be easier to just refuse to do services during an office visit that you know you won’t get paid for. Either way, “physicians just need to squarely face this. No amount of ducking and shuffling is going to make it go away,” Dacey says.

Learning to Code for Time

Physicians also need to face up to their choices when it comes to coding E&M visits. Whether done in the inpatient or outpatient setting, many E&M codes allow physicians to select a level of service based either on the nature of the history, exam, and medical decision-making, or, if it takes up more than half of the visit, on the time spent counseling the patient.

“Physicians have gotten a little more used to coding for time in the office. … When they are in the office they’ve got nurses, they’ve got managers, they’ve got people around to help them,” Dacey says. Someone might point out that the physician just spent 25 minutes mostly talking about how a given patient should handle her medications, and that that could make the visit a level 4 instead of a level 3.

“But in the inpatient setting, there is no one there to help them,” Dacey points out. Plus, in the inpatient setting, the time spent need not be face to face with the patient. It just needs to be time spent on the floor or unit or with other healthcare professionals related to that patient’s care. That can easily add up to more time than physicians realize is going by. If they do realize it, they may feel awkward making a note about time spent (as required by documentation rules) in the patient record. “Physicians might think that looks a little tacky in the inpatient setting,” Dacey acknowledges. “To all of a sudden to tack on this reference to time and to billing it just doesn’t look good, some people have an aversion to it.”

The end result? “It’s clear to me that physicians shoot low in their coding in the inpatient setting based on time. … An admission may be a lower level code based on severity but it could be a higher level code based on time, and physicians routinely don’t recognize this.”

After Hours and Prevention

Nancy M. Enos, director of physician services for LighthouseMD, a practice management consultant in Providence, R.I., also encourages physicians to pay attention to the extra things they’ve gotten used to doing that might be billable, if properly documented and coded.

One example? After-hours codes. “After-hours codes have caused confusion for many years,” says Enos. “Check your insurance contracts to find out if your specialty qualifies for use of the codes, and what insurance carriers will pay for them.” The Sunday and holiday code (99052) is covered for office services (as long as the office is not open according to posted office hours) provided on Sundays and New Years Day, Washington's Birthday, Memorial Day, Independence Day, Labor Day, Columbus Day, Thanksgiving Day, and Christmas Day. Services requested after posted office hours (99050) are covered for certain specialties including primary care, pediatrics, and obstetrics, says Enos. “Office services provided on an emergency basis (99058) should be supported by a chief complaint and history that clearly describes the emergent nature of the visit,” she advises.

Keep an eye, too, on preventive services. Medicare, which traditionally hasn’t covered preventive care, has recently expanded the things it will pay for. Coverage for smoking cessation counseling is one example. Since March 22, 2005, Medicare Part B covers two new levels of counseling - intermediate and intensive - according to Enos. Here are the codes:

• G0375 - Smoking and tobacco-use cessation counseling visit; intermediate, greater than three minutes up to 10 minutes.

• G0376 - Smoking and tobacco-use cessation visit; intensive, greater than 10 minutes.

To bill for smoking cessation counseling provided on the same day as an E&M service, use the appropriate code in the 99201-99215 range and modifier 25 to show that the E&M service is a separately identifiable service from the counseling, Enos suggests.

And don’t forget to bill for Medicare’s new initial preventive physical exam (IPPE) if you are providing and documenting that service, she adds.

The challenges of contemporary healthcare are big enough without making simple errors. Correct your coding and get what you deserve.

Pamela Moore, PhD, CPC, is senior editor ofPhysicians Practice. She can be reached at pmoore@physicianspractice.com or via editor@physicianspractice.com.

This article originally appeared in the February 2006 issue of Physicians Practice.