Medicare Compliance & Reimbursement

Billing and rendering provider must be in the same group.

You may think you know your ABCs when it comes to billing and coding compliance, but one carrier is preparing to give you a spelling test.

Cahaba GBA imposed a new set of "audit trail" edits starting March 1. They are looking to see if providers are following basic compliance on several billing and coding issues, including:

• Use of LC/LD/RC modifiers for coronary procedures. If you bill for a coronary procedure without one of these coronary artery modifiers, you may face a denial. "RC" stands for right coronary artery, "LC" stands for left circumflex artery, and "LD" stands for left anterior descending coronary artery.

• Use of LT/RT for cataract surgery codes. You need to use these modifiers to identify which eye the surgeon operated on, Cahaba warns.

• Use of the QX/QZ modifiers for CRNA. If a certified registered nurse anesthetist served as the assistant anesthetist during surgery, you need to apply the QX (With medical direction) or QZ (Without medical direction) modifiers to let the carrier know if the CRNA had a doctor's supervision. If an anesthetist supervised the CRNA, you'd also attach the QY (One CRNA) or QK (Two to four CNRAs) modifiers to the anesthetist's claim.

• Name of facility. Providers are forgetting to attach the name and address of the facility where they rendered services.

• The billing and rendering providers must be in the same group. On some recent claims, providers have attached a provider number that's not associated with the group number on the claim, Cahaba complains.

• Unspecified procedure codes. If you use a miscellaneous procedure code, such as J3490, you need to include a description of the services the physician rendered, or you'll receive a denial, Cahaba warns.

The Medicare carriers in New York and New Jersey don't seem to have edits like Cahaba's yet, notes Jim McNally, third-party coding specialist with Health Care Consultant Services in Flushing, NY.

"It wouldn't surprise me if other carriers had these edits," says Cindy Parman, co-owner of Coding Strategies in Powder Springs, GA. "Most of them look like common-sense issues."

Cahaba's new edits are good news for providers, McNally adds. "The more specific the edit/denial is, the better it is for the physician," he explains. These edits will give coders a specific explanation of what information they left out, instead of a standard "information is missing or invalid" message.

Providers do sometimes forget to apply basic modifiers such as the CNRA, left/right or artery ones, McNally notes. "That is why I stress the use of modifiers in educational presentations."