Medicare Compliance & Reimbursement

Be prepared for your carrier to demand out-of-date modifiers.

Don't take your carrier's anesthesia policies for granted, or you could be lulled into a false sense of security.

Different carriers expect different anesthesia modifiers, warned Kris Simeona from University Hospital in Salt Lake City in her "Anesthesia Coding Boot Camp" talk at the 2007 American Association of Professional Coders conference in Seattle.

Tip #1: Check with your carrier to make sure it accepts the usual Monitored Anesthesia Care (MAC) modifiers, Simeona urged.

When University Hospital's anesthesia practice switched carriers to Noridian in 2006, Simeona received a raft of denials for MAC because Noridian's system couldn't accept the G8 and G9 modifiers. By touching base with Noridian, she was able to get these claims paid.

Tip #2: Make sure the carrier is actually following its own policies, Simeona advised.

After changing carriers to Noridian, Simeona's medical necessity rejections for MAC almost tripled. Noridian had updated its local coverage determination (LCD) but hadn't updated its system. So even though her codes were correct according to Noridian's LCD, she was receiving denials.

Tip #3: Contact your carrier if you don't see a MAC policy online, Simeona said.

There's no consistency on carrier policies for MAC, Simeona lamented--and some carriers forget to post their policies at all. In one case, a carrier had taken down its MAC policy to revise it but forgot to put it back up.

Tip #4: Be aware if your carrier is expecting older anesthesia codes. Some payors may not recognize new American Society for Anesthesiology (ASA) guidelines and codes, she added. In fact, some payors are still stuck using 1996 guidelines and codes.

If you know your carrier is looking for older codes, you can set up an edit in your system. This edit should "backmap" to the code your payor wants to see. That way, "you've saved yourself time and money," Simeona said.

Simeona has one payor that only reads the first modifier on a claim. This creates "huge back-end appeals."

Tip #5: Meet with every payor every month, and communicate all issues. Simeona also documents all issues on the record and tracks them. This way, you have everything in writing and the payor has all the same documentation you do.

Tip #6: Ask your payor for concrete deadlines by which you'll get paid. "I usually ask for a two-week turnaround," Simeona explained. In the case of one Medicare carrier, it took four months, but a year's worth of claims were involved, she added.