Advanced Search

General Surgery Coding Alert

Facilitate Billing:

Use Modifiers, Diagnosis Codes Properly

Published on Mon Apr 01, 2002

Thorough knowledge and use of modifiers and diagnosis codes are key to efficient billing and reimbursement, says Kathleen Mueller, RN, CPC, CCS-P, a general surgery coding and reimbursement specialist in Lenzburg, Ill.
 
"Carriers deny claims for a lot of different reasons," Mueller says, "but the majority of denials are the result of incorrect modifier use and the wrong ICD-9 code."
 
You can improve coding by consulting physicians before negotiating with private payers, considering some private payers adhere to coding guidelines that differ substantially from guidelines listed in the Correct Coding Initiative (CCI), the Medicare Carriers Manual and the local medical review policies (LMRP) of individual Part B carriers.
 
 
Brush Up on Modifiers. Incorrect modifier use tops the list of reasons why claims are denied.
 
The wrong modifier was used, or a modifier was not used when it should have been, or vice versa, says Arlene Morrow, CPC, a coding, reimbursement and compliance specialist in Tampa, Fla.
 
If the results of a diagnostic breast biopsy (19100*) lead your physician to perform a partial mastectomy (19160) later the same day, for example, Medicare guidelines published in CCI version 7.3 state that you should append modifier -58 (Staged or related procedure or service by the same physician during the postoperative period) to 19160.
 
You risk the claim being denied if modifier -58 is either not appended to 19160 or substituted with -59 (Distinct procedural service) or -51 (Multiple procedures).
 
Note: Modifier preference tends to be carrier-specific. Although some carriers may now prefer -58, others may prefer -59 or some other coding technique. If you have a private carrier, obtain its policy on use of these modifiers in writing.

Ensure Diagnosis Code Provides Medical Necessity. When the wrong diagnosis code is associated with a procedure, the carrier may deny the claim because medical necessity has not been demonstrated, Morrow says. Surgeons occasionally forget to update the diagnosis in the patient's chart, which can lead to denials if the ICD-9 code is not updated.
  
"We often do not show medical necessity clearly enough. We slap on a diagnosis when the patient comes in and it never gets changed," she says.
 
"A belly ache may be the reason the surgeon first saw the patient, but if the surgeon determines the patient has appendicitis and performs an appendectomy, the change from belly ache [i.e., 789.06] to appendicitis [i.e., 540.9] should be made when billing for the appendectomy."
 
The abdominal-pain sign or symptom may not provide medical necessity for the appendectomy, Morrow adds. Diagnosis coding is particularly scrutinized for vascular procedures, she notes.
 
Morrow recommends that vascular surgeons and their coders become familiar with LMRPs that include Medicare's indications for a given procedure, the covered diagnoses corresponding to those indications, and the documentation requirements so medical necessity for a given procedure can be clearly indicated.
 
Demonstrating medical necessity will require more extensive documentation that explains the particular circumstances involved and supports the diagnosis code associated with the procedure or service.

Double-Check Records for Noncoding Errors. Claims are denied for a variety of reasons, many of which are unrelated to physician coding.
 
Mueller says, "You can waste a lot of time looking for coding errors when a simple phone call to a carrier's provider-relations department can sort out the issue quickly."
 
She points out that a spotcheck of patient and carrier records can also uncover incorrect policy or Social Security information, physician credentialing or patient information that left undetected would result in fruitless attempts to find a coding solution.
 
Morrow urges practices with several coders to designate one coder as a denial specialist or "EOB [explanation of benefits] hawk."
 
This coder "will quickly become familiar with denied codes and claims, and can sniff out these sorts of errors fast," she says.

Send Coder to Carrier Contract Negotiations. Commercial carriers sometimes create and implement coding guidelines that do not adhere to established CPT or Medicare coding principles, Morrow notes.
 
As a result, they often create edits that are not in the CCI, or do not recognize certain CPT codes and modifiers, even though these are part of the coding principles surgeons and their coders are supposed to use.
 
The surgeon must adhere to these terms once they are in the contract.
 
Unless a coder is present who understands the significance of the carrier's specific guidelines, items that can greatly affect reimbursement may be overlooked by the negotiating team, which typically consists of physicians and management or marketing personnel.
 
Because they are the professionals in this critical area, Morrow urges coders to volunteer and provide input to the management team, which may have little coding knowledge and may not realize the significance of seemingly innocuous coding guidelines.
 
"We assume carriers pay us according to well-known coding rules and conventions, but often they don't," Morrow says.
 
"So we need to make sure that when we review our contracts, our claims are being assessed using current CPT and Medicare guidelines."
 
A classic example is when carriers deny claims for E/M visits that resulted in decisions for same-day procedures, even when modifier -25 (Significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service) or -57 (Decision for surgery) is appended to the appropriate visit code.
 
Carriers may also arbitrarily extend the accepted length of an observation stay from 24 to as many as 72 hours, Mueller says, with the hospital and the physician reporting different place-of-service codes complicating reimbursement.
 
For example, a general surgery office has claims denied for several hospital visits for a woman that were billed as follows:

Day 1  99251-99255 (Initial Inpatient Consultations series)
 
Days 2-3    99231 (Subsequent hospital care, per day, for the evaluation and management of a patient ).

The denial included the message: "Place of service illogical."
 
It was discovered that the carrier has a policy of 72-hour observation. For this carrier, the claim should have been coded as follows:

Day 1  99241-99245 (Office or Other Outpatient Consultations series)
 
Days 2-3  99212 (Office or other outpatient visit for the evaluation and management of an established patient ).

The place of service should be listed as "outpatient hospital," Mueller says, noting that the message "Place of service illogical" usually indicates that the hospital billed a different place of service.
 
Note: The hospital may be more familiar with the carrier's policy and may, therefore, include the hospital outpatient place of service. Ask the hospital how it views the visit (inpatient or observation) before submitting the claim.

Other Articles in this issue of

General Surgery Coding Alert

View All