Medicare Compliance & Reimbursement

If you're not up to date on codes, you could be losing cash.

Facing hard times in your practice? You're not alone. Many practices are coping with tight reimbursement and declining revenues. Reasons include high-deductible health plans, the quick growth of Medicare Advantage and a cut to most work RVUs, says Randall Karpf, an independent coding consultant in East Hartford, Conn.

Practices tell us they've seen a sharp drop this year. "Reimbursement is down all over," says one coder with a cardiology practice in New York state. Her practice hired an outside consultant, but that person couldn't figure out the plummeting income either.

It gets worse. The coder says one local group couldn't make its payroll "and had to take out a loan to keep the office going." And the group may have to take out another loan the next time payroll comes around, the coder adds.

In this tough environment, you can't afford to make mistakes. The following 6 tips could help your practice find money where it might be falling through the cracks:

1) Understand the code definition. If the coder or biller doesn't really understand what a specific code means, you could be missing out on revenue. And bear in mind that even if a code remains the same, the code description could change from year to year.

2) Update new codes immediately. This includes adding them to your charge tickets and software. Bear in mind that codes can change throughout the year. For example, Medicare introduced codes 0223T--0233T on Jan. 1, 2010, with a July 1, 2010 implementation date.

3) Keep track of your denials. In some practices, the "payment posting" department automatically writes off the amount that the payer didn't reimburse. You should be appealing these denials where necessary.

4) Review ancillary codes. Suppose a practice performs and documents tobacco cessation counseling. But the practice hasn't billed Medicare for 99406"99407, the codes for this service, which can earn you between $11 and $25 per visit. "Or worse yet," Karpf says, "you have the foresight to bill for the tobacco cessation counseling, but you charge it using the old temporary G codes, and collect nothing."

5) Analyze your managed care contracts. Many practices sign managed care contracts that promise a percentage ofMedicare reimbursement. So when Medicare slashes RVUs, or makes a 21 percent payment cut, your managed care pay will drop automatically.

6) Understand modifiers. You shouldn't ever overuse modifiers or report them automatically, and you should always be wary of modifier 59, which is certainly valid if you perform a distinct procedural service -- but not as a catch-all to undo CCI edits. At the same time, you should be aware of when it's appropriate to use a particular modifier and be willing to add it when necessary.