Gastroenterology Coding Alert

Use This Field-Tested Checklist to Make Your Work More Efficient and More Effective

Gastrointestinal coding is part art form, part mechanics. Successful coding requires accuracy, persistence and constant attention to detail. Above all, great coding is about "knowing the rules, the specific rules for each carrier even if they are inconsistent with the rules of other carriers or even the standard CPT rules or Medicare's rules," says Michael Weinstein, MD, a gastroenterologist in Washington, D.C., and a former member of the CPT advisory panel.
 
By mastering certain basic practices - and making them second nature - you'll be ahead of the game when it comes to beating the odds on reimbursements and appeals.
 
Use the tips below to make sure you've covered the basics of correct coding:

 1. Sweat the small stuff. Understanding your carriers' rules about how to use modifiers can increase your reimbursement potential. For example, Sherri Brasher, insurance and billing specialist with Gastroenterology Associates in Evansville, Ind., understands how her carriers want multiple-procedure modifiers used - and it's made a huge difference in the success of their billing. "Sometimes we use -51 (Multiple procedures), but with some carriers we use -59 (Distinct procedural service), especially with some of our commercial insurances because they won't pay with the -51. Instead we've been attaching -59 and -51, letting them know it's distinct and separate, and also it's multiple procedures."

 2. Speaking of the small stuff ... Strive for the most detailed diagnosis you can. Fourth and fifth digits on ICD-9 codes will improve your chances of getting reimbursed and, more important, they provide you with a greater capacity for patient tracking and disease management.

 3. Always base your coding on medical record documentation. Be fanatical about reviewing documentation to be sure the record supports the codes selected. It helps to have all of the patient's documentation in front of you so you can make the proper choices while you're coding, says Jill Barron, CPC, coding manager for Gastroenterology Associates of Cleveland. "I also code all of my procedures off of the op reports, so I don't even enter the procedures until I have the op reports," she adds.
 
And never assume! If you have a question about a code or a comment your physician has made in a patient's record, do not assume what she meant. Guessing or submitting paperwork you don't feel comfortable with will come back to bite you. Always speak with the physician, Barron advises. "I'm not going to assume. I always go back to them."

 4. Formalize error-checking. Regularly check billing reports for minor errors - before they go out - to prevent denials and payment delays. Keep a "Most Wanted" list to remind yourself of the most common errors. Brasher and her colleagues at Gastroenterology Associates shut down small errors before they get out the door: items like incorrectly listing a place of service, leaving off a modifier, or not matching the diagnosis code with the procedure performed.
 
The result is a tremendous savings in time and money, she says. "We are taking that report, looking at it before we submit it, making our corrections and then sending it on. We're not getting those silly little denials, like place of service. It has really been incredible the time it has saved us - and [it saves time on the] reimbursement, too. You know we're getting that reimbursement a lot quicker."

 5. Be a bulldog with appeals - fight those denials. "Reimbursements have really changed [in our practice] in the last year because we have been persistent with our appeals," Brasher says. She recommends doing your research and then insisting that carriers honor the guidelines. "We can bill for [appropriate procedures], according to our CPT guidelines, and we will. And we will be aggressive with fighting them." This can mean taking matters to a higher authority as well. "We have one culprit that we're in the process of turning over to the insurance division. We pushed and pushed and pushed, and they pushed back. We finally said, "OK, we've had enough, now we're going [to the insurance division] ... and that's what it takes. It takes persistence." Brasher's success rate with appeals has improved dramatically.

 6. Be a smart bulldog, too: Get personal with your appeals. Another factor contributing to Brasher and her practice's success with appeals has been their adoption of a very personalized, directed, comprehensive appeals process. "When we started going to a more personalized letter, that's when we started getting reimbursement," she says.
 
In addition to quoting from the CPT guidelines in her documentation, Brasher personalizes a standard appeals letter template. "I try to get the doctor involved with it, especially with his dictation. It forces [carriers] to read it. Too, in our letter we ask that [the appeal] be reviewed by someone in the specialty," Brasher says. She believes that this gets their appeal more attention and a more attentive, informed reviewer, which means success for the practice.

 7. Check and keep a record of carrier updates. Stay consistent with updated information: new ICD-9 codes, new NCCI edits, carrier bulletins and explanation of benefits (EOB). Staying current with this new information will give your practice a leg-up on the road to new opportunities and out of the noncompliance ditch. Most updates come on a regular schedule, so mark your calendars to remind yourself to read these immediately upon release.
 
A quick scan can tell you whether there's news relevant to your practice or specialty. Share key updates, journal articles or other specialty-specific materials with your billing staff to support tricky codes. And don't forget to stamp a date on those releases and store them chronologically for easier reference, one coding expert says.

 8. Run system reports to discover claims with invalid codes. Once new codes take effect, you need to find existing patients with codes that are no longer valid and correct those codes. This is another activity you can schedule based on the ICD-9 and NCCI release calendar.

 9. Document information on (upcoming) new codes. In addition to revising the old codes, anticipate the new. Being familiar with your carriers' local medical review policies (LMRPs) on new services will help you understand what documentation will be required once a new edit goes into effect. The draft versions of these LMRPs are usually available for some time before the actual change starts. Take note of the effective date for the new codes, as well.

 10. Know thy carriers. Your local Medicare carriers and private insurance companies will all have their own ways of doing things. Note what they accept, what they deny, and why. What documentation do they require to approve claims? Study denials and approvals for tips on what works with whom. Keep a cheat sheet that notes any special coding instructions you should use to maximize payment and minimize denials. And get involved with their LMRP processes whenever possible.