Medicare Compliance & Reimbursement

Cap could be once-in-a-lifetime opportunity -- to lose money.

Heads up, surgery practices: Asking a few questions up front could make a huge difference to your financial health.
 
For example: Many insurers are now imposing financial limitations on colorectal procedures, especially bariatric and weight-loss surgeries. In some cases, a patient may have a lifetime limit on gastric surgeries as low as $25,000, says Arlene Morrow, president of AM Associates in Tampa, FL.

So surgeons may be treating a patient for abdominal pain or some other gastrointestinal diagnosis, and only finding out afterwards that the patient has already used up his lifetime amount. You "may need to go the extra mile and obtain some kind of deposit" before surgery, she adds. Otherwise, the patient could refuse to pay on the grounds that he wouldn't have agreed to the procedure if he'd known it was non-covered.

You should also obtain preoperative clearance from your Medicare payor or other carrier to make sure the patient is a good candidate for a particular procedure beforehand, Morrow adds.

Similarly, you should contact the patient's insurer before surgery and check whether the patient has any deductible. For surgeries, a deductible could be as high as $2,500, plus a 20-percent copayment. "You need to know all this when the surgery is scheduled, so you can deal with it," says Catherine Brink, president of Healthcare Resource Inc. in Spring Lake, NJ.

Code for time: You may be undercoding preoperative visits, warns Morrow. Often, the surgeon will send the patient for tests. Then the patient comes back to go over the results and discuss treatment options, including surgery. Often, you can code these "informed consent encounters" as counseling and coordination of care (C&C), notes Morrow.

A preoperative visit that consists of going over test results and discussing the need for surgery might only qualify as a 99212 based on the three elements, says Morrow. But if the surgeon spent 45 minutes to an hour discussing the surgery, you could bill a 99215 for C&C, based on time.

Warning: But a vague note like "a lengthy discussion" won't cut the mustard, Morrow adds. The note must say exactly how much time the surgeon spent with the patient. Otherwise, you might lose that extra reimbursement in an audit.

Important: Make sure you append the 57 modifier (Decision for surgery) for any pre-operative visits if they take place the day of surgery or the day before, says Patrick Cafferty with Neurosurgical Associates of Western Kentucky in Paducah, KY.