Neurology & Pain Management Coding Alert

Pay special attention to claims with modifiers 25 and 59 If you-re not conducting internal chart audits for your neurologist, you may be giving up thousands of dollars that your practice is rightfully entitled to. Uncover Potential Problems Through Audits -Not only will a chart audit uncover documentation and coding errors, but missed revenue is often found -- services that should have been reported but were not captured,- says Deborah Grider, CMA, CPC, CPC-H, CPC-P, CCS-P, CCP, EMS, president of Medical Professionals Inc. in Indianapolis and American Academy of Professional Coders National Advisory Board president-elect.

Example: -The billing staff at one [physician practice] failed to report any modifiers for office encounters, costing the practice $30,000 in unpaid services that year,- says Curtis Udell, CPAR, CPC, CMPA, senior advisor with Health Care Advisors Inc. in Annandale, Va.

Udell also remembers one audit that uncovered improper modifier assignment, and the practice had no claims correction or appeals processes. -It cost the practice $450,000 in revenue in one year,- he says. Audit Your Most-Used Procedure, E/M Codes When you are conducting your internal audit, focus on the billing issues that will most likely disrupt the office's cash flow or cause compliance issues.

Internal audits should largely focus on the following areas, according to Ian S. Easton, PhD, head of Applied Technology at Coastal Georgia Community College in Brunswick:

- areas the HHS Office of Inspector General (OIG) plans to target in its Work Plan. These include level-five consults, level-two follow-up hospital care, and level- four follow-up office visits. See http://oig.hhs.gov/authorities/docs/physician.pdf to stay up-to-date on the OIG's Work Plan.

- higher-level E/M codes.

- high-cost procedures that the practice performs often. EMGs and Botox injections are two of the biggest -- and most common -- neurology procedures you should always watch closely to ensure correct reporting.

Starting point: Base your audits on your neurologist's utilization patterns and the billing areas the insurance carrier is concerned with, Grider says.

For example: An audit of the reporting practices of Provider B for the last six months indicates that Provider B has reported 20 level-five new patient E/Ms (99205, Office or other outpatient visit for the E/M of a new patient, which requires these three key components: a comprehensive history; a comprehensive examination; medical decision-making of high complexity) and only seven level-three new patient visits (99203, ... a detailed history; a detailed examination; medical decision-making of low complexity).

The audit shows that Provider B's coder could be reporting some services incorrectly. In this instance, make sure that Provider B can justify the E/M levels, or the office might be marked with -billing outlier- status -- meaning that many of the physician's services are being coded -outside the norm.-

Tip off: Having so [...]