Anesthesia Coding Alert

If you've compiled a list of your top-10 denials, comparing your top denial reasons with Medicare's will help you determine where you stand compared to other practices' most frequent denial reasons. Last month's Anesthesia & Pain Management Coding Alert looked at three denial-prone areas for anesthesia practices: improperly bundled services, duplicate claim submissions, and misused modifiers.

Now our experts share their views on three more issues that crop up in anesthesia or pain management practices, and how you can conquer them.

Try this: Check your Medicare carrier's own top-10 reasons for denying claims, or check the box on page 19 for the top-10 reasons for denials nationally.

Reporting the correct diagnosis for a procedure is just as important as correctly coding the procedure itself.

Some procedures have "flags" and a list of approved diagnoses, says Jann Lienhard, CPC, a coder in New Jersey. If the payer doesn't believe your diagnosis supports medical necessity of the procedure, the payer will deny your claim.

Watch for these common diagnosis mistakes in your coding:

• Not updating a pain management patient's diagnosis. For example, administering an epidural or blocks with a vague diagnosis such as "back pain" can result in quick denials.

• Changes in an obstetric patient's status. For example, an expectant mom comes to the hospital in labor. After 14 hours, her labor stops and she returns home. She returns three days later and delivers. The payer will deny your claim if you report both cases with 01967 (Neuraxial labor analgesia/anesthesia for planned vaginal delivery [this includes any repeat subarachnoid needle placement and drug injection and/or any necessary replacement of an epidural catheter during labor]) with diagnosis 650 (Normal delivery).

• An incorrect diagnosis for post-op pain management. Many payers have specific guidelines for the diagnoses they consider acceptable for postoperative pain management, says Scott Groudine, MD, an anesthesiologist in Albany, N.Y. Empire in New York, for example, lists only three diagnoses to justify 01996 (Daily hospital management of epidural or subarachnoid continuous drug administration) and epidural codes 62310-62319. Empire accepts 338.11 (Acute pain due to trauma), 338.12 (Acute post-thoracotomy pain) and 338.18 (Other acute postoperative pain). Because of these types of stipulations, always verify your payer's policy for post-op pain management.

Helpful: Some mistakes can be a simple matter of keying the wrong diagnosis, Lienhard says. If you receive a diagnosis-based denial, verify that you didn't submit a claim with a typo. If the diagnosis you submitted was correct but isn't on the payer's list, talk with your physician. A secondary diagnosis he documented might work just as well.

Billing Medicare as the primary payer when it is, in fact, the secondary carrier is a common problem for all specialties. Medicare has even stepped in to find and correct these situations.

"CMS has hired recovery and audit contractors (RAC)," Groudine says. "These are active in New York, Florida and California as a Medicare demonstration project. Now Congress has deemed this a success, and RACs will have a presence in all 50 states in 2008."

One of the auditors' responsibilities is to verify if a patient's primary insurer and Medicare have both been billed for a single claim or if Medicare paid when the patient's primary insurer should have paid instead. In both situations, the RAC will verify the billing errors, including any potential underpayments and begin recovery of any controversial overpayments.

Billing the incorrect carrier can be a common problem, according to Lienhard. "The patient presents your office staff with a Medicare card because Medicare tells her to do this when she first receives her card. Your front desk or registration staff must have the ability to question patients about other insurance and see their cards."

Tracking tip: Some Medicare patients do have a flag on their ID card to indicate other coverage, but Lienhard says most do not. She has designed a simple information page for those patients; she completes it with the patients and gives them a copy to pass along to all of their providers. "It's a nice service. It just takes a minute, and the patients appreciate the help," she says.

Ideally, most of the services your physician provides will be reimbursable. Watch for services that Medicare doesn't cover (such as blepharoplasty without visual defect or breast reduction without mastectomy) and keep these pointers in mind:

• If you believe your physician has scheduled a non-covered service, talk to the patient beforehand. Explain the procedure and the payment situation, and ask the patient to sign an Advance Beneficiary Notice stating that she will personally pay for the service if the carrier refuses. Share a ballpark figure for the procedure so the patient knows what she's agreeing to.

• Denials that are in this category often are due to performing too many services within a timeframe, Lienhard says, such as exceeding your limit for trigger point injections (20552, Injection[s]; single or multiple trigger point[s], one or two muscle[s], and 20553, ... single or multiple trigger point[s], three or more muscles). Know the payer's requirements and work to gain pre-approval for additional procedures if you expect to exceed the payer's limit.

• Fight for the patient and your funds from the carrier. Many times, the carrier will review the case manually and approve the payment.

• Even if you know Medicare doesn't cover a service, you must still report it. Some secondary carriers will only pay when you can show an initial denial.

Remember: Not every insurance denial automatically means your practice made an error. If you scrutinize your EOBs carefully, you might find that you are wrong some of the time and that the insurer is wrong sometimes. In some instances, you might simply need to notify the payer why it was wrong to reject your claim.