General Surgery Coding Alert

Update files from WPC website.

Who knew that the Remittance Advice (RA) statement you receive from your Medicare MAC after you file a claim could be such a helpful tool for your surgery practice?

But RAs (and the electronic version, ERAs) are chock full of information about payment, adjustments, and any reasons you might not be getting the pay you expected for a service.

Read on to see how you can unlock the mysteries of RAs and put them to work for your practice.

Take a Bead on RAs

Medicare will send an RA or ERA to your practice after you file a claim, and based on HIPAA electronic transactions requirements, the payer must use valid, standard codes in the communication.

Two codes fit the bill: Claims Adjustment Reason Code (CARC), and Remittance Advice Remark Code (RARC). These codes provide policy information that applies to monetary adjustment, and supplemental explanations for further clarity.

Distinguish EOB: An RA is distinct from an Explanation of Benefits (EOB), which Medicare (and other payers) will send to the patient, not your practice.

“EOBs are insurers’ way of explaining their reimbursement [to the patient], based on the CPT^® codes and ICD-10 codes submitted,” says Catherine Brink, BS, CMM, CPC, president of Healthcare Resource Management in Spring Lake, New Jersey.

Both RAs and EOBs contain similar information, such as the following, according to Melanie Witt, RN, MA, an independent coding expert based in Guadalupita, New Mexico.

• Information regarding the patient
• The service provider
• Any adjustments made to the claim
• The type of procedure performed
• The date the procedure was performed
• The cost of the procedure
• An explanation if the payment was denied.

The major difference between RAs and EOBs is that an EOB contains a disclaimer stating the EOB is not a bill, according to Witt.

Translate CARC/RARC

When you receive an RA or download an ERA, you need to be able to translate the CARC and RARC to understand what’s happening with the claim in terms of payments, adjustments, or denials.

Tip: You can convert ERAs into readable formats using software such as Easy Print or PC Print, which you can download for free from CMS at www.cms.gov/Research-Statistics-Data-and-Systems/CMS-Information-Technology/AccesstoDataApplication/MedicareRemitEasyPrint.html or www.edissweb.com/cgp/software/pcprint.htm.

Translate: The alpha-numeric CARC and RARC themselves won’t tell you much. To get full definitions, you can go to the website of the Washington Publishing Company (WPC), which manages the codes (http://wpc-edi.com/Reference/).

Once at the website, you can click on the link for “Claim Adjustment Reason Codes (CARC)” to see complete list of current codes with their definitions, such as, “6 - The procedure/revenue code is inconsistent with the patient’s age.” You’ll also find a link for “Remittance Advice Remark Codes (RARC),” which provides a complete list of current codes with definitions, such as “M43 - Payment for this service previously issued to you or another provider by another carrier/intermediary.”

Stay up to date: MACS update CARC and RARC three times annually based on WPC’s schedule, typically March 1, July 1, and November 1. That means your practice needs to keep current with the updates if you want to be able to translate your RAs. In addition to the updated list of codes, the website also contains links to deactivated codes, and codes scheduled for deactivation at the next update. To read more about updating these codes, check out the July 1, 2018 MLN Matters article MM10489 at www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/Downloads/MM10489.pdf.

Who’s responsible: If the claim is denied, the group code will tell you who has the financial responsibility: CO (Contractual Obligation) assigns responsibility to the provider, while PR (Patient Responsibility) means the patient must pay, according to CMS.

Track Denials to Improve Claims Accuracy

Surgery practices can utilize their RAs to streamline their processes. Tracking RAs will help you identify rates of claims denials, and categorize reasons for them. With that information, you can improve your practice’s claims accuracy and maximize legitimate payment for services.

“All billing staff should spend time studying the reasons cited for adjustments or denials from the RA they received,” Witt says. Track RA messages to find any patterns of inappropriate adjustments, such as incorrect modifier use, bundling problems, secondary procedure reduction, among others, she advises. Also look for denial reasons, such as, code not covered, not medically necessary, demographics incorrect, etc.

Track pay: Billers should also use RAs to compare payment received to the published fee schedule from the insurer, Witt adds.

Focus on denials: Using denial information from RAs, you can analyze trends that are costing you money. “Compile your data into a denial trend report that lists reason codes, remark codes, and group codes. Sort your report by reason code so that you can quickly spot denial trends,” suggested Maggie Fortin, senior manager at Baker Newman Noyes, presenting at the American Academy of Professional Coders’ Healthcon meeting earlier this year.

Once you’ve uncovered denial trends and root cause, you can take steps to reverse them. This may involve educating staff, educating clinicians, beefing up your ABN procedures, redesigning workflows, reviewing NCDs and LCDs, or refining your ICD-10 coding to better express medical necessity, according to Fortin.