Cardiology Coding Alert

Hint: Make sure you don’t submit duplicate services/claims.

If you report arterial and vascular services on the same day, check out the latest prepayment review from National Government Services (NGS), which delved into JK Part B claims for 2017. The NGS review resulted in the Medicare payer reducing or denying more than 85 percent of claims in January, February, and March.

Don’t worry: In its review, NGS gave the reasons for the reductions and denials, and we’ve got tips to help you avoid making these same mistakes in your practice.

See Which Codes the Review Centers On

The NGS report focuses on claims that people billed with the following duplex scan codes:

• 93880, Duplex scan of extracranial arteries; complete bilateral study 
• 93882, … unilateral or limited study 
• 93925, Duplex scan of lower extremity arteries or arterial bypass grafts; complete bilateral study
• 93926, … unilateral or limited study
• 93970, Duplex scan of extremity veins including responses to compression and other maneuvers; complete bilateral study
• 93971, …unilateral or limited study.

Mistake 1: You misinterpreted what supports medical necessity.

The following mistake has become more commonplace and occurs for a few different reasons, according to Mari Robinson, A.A.S, CPC, CRC, CCC, compliance analyst of chronic conditions at Riverside Medical Group in Newport News, Virginia:

• 1: The documentation lacked clinical indications to support the medical necessity of the study; such as, relevant medical history, physical exam, pertinent diagnostic studies/results, etc.

“Physicians normally work within the IP [inpatient] and OP [outpatient] environment,” says Robinson. “If providers have not been educated on the different compliances for these two billing areas, it can be challenging to code from their documentation.”

Robinson adds that hospitalists may not be experienced enough to document all of the information required for diagnostic testing.  

“Clinical indicators can be missing, and their [hospitalists’] experience has not led them to think all the way through the pathophysiology for specific testing that needs to be done for certain symptoms,” Robinson says. “Or they simply do not yet know which diagnostic testing should occur with certain symptoms.”

Inpatient setting: Within the IP setting, the compliances states that the coder can code “rule out,” “uncertain,” or “suspect,” according to Robinson.

Outpatient setting: Within the OP setting, the terms “rule out,” “uncertain,” or “suspect” are considered unacceptable terms in a note and the coder may not code them, Robinson says.

The challenge comes when physicians become confused while going between the two billing departments and the compliances, so they may forget to document accordingly, Robinson says.

“They may not be aware that diagnostic testing has to be supported by clinical indicators or other requirements of compliance for reimbursement,” says Robinson. “They are simply looking at symptoms and trying to narrow down the condition to establish a diagnosis.”

Tip: Robinson says that education is the key to avoiding this mistake.

“There must be a compliant provider query process in both the OP and IP setting,” says Robinson. “The physicians must be approached with education in a way that will provide them with confidence and assurance from the coder or compliance team and not condemnation.”

Mistakes 2-3: You ignored CMS’s documentation requests.

Never put off providing the medical documentation your Medicare Administrative Contractor (MAC) asks for.

Here are two major mistakes other coders have made:

• 2: Providing no response to requests for medical documentation
• 3: Not submitting documentation for the billed CPT^® code(s).

Tip: When your MAC performs a prepayment review or audit and asks for specific documentation to support your claim, you need to know which code(s) the payer wants to see support for, turn the appropriate documentation in, and submit the requested information in a timely manner.

Mistake 4: You don’t have a strategy to prevent duplicate claims.

To avoid making this fourth mistake, make sure your submit a legitimate second service, not a duplicate claim.

• 4:  Billing/submitting duplicate services/claims.

Medicare has a strict policy to not pay duplicate claims for the same service encounter, according to the January 2015 Medicare Quarterly Provider Compliance Newsletter. Medicare will pay for the first claim that is approved and deny subsequent claims for the same service as duplicates.

Tip: If you haven’t been paid for a first claim, check the claim’s status with your MAC. If you discover an error on your initial claim, follow the MAC’s instructions on how to correct the error instead of submitting a second claim for the same service.