Save Time by Creating a Payer-specific Coding Policies Log
Published on Sat Jul 01, 2000
Many neurologists see patients in a variety of inpatient and outpatient settings, and many of these patients are covered by a wide array of health plans. In addition, neurologists and neurology billing and coding companies may submit claims for patients who are visiting the area but have insurance coverage in different cities and different states.
Billing requirements and policies often differ from payer to payer. Karen Duane, CPC, coding specialist for the Barrow Neurological Institute, which has 20 neurologists in Phoenix, says that different carriers and third-party payers may have varying guidelines about what conditions warrant epidural blocks (62310-62311, 62318-62319, 62280-62282, and 64479-64484), so it is important to keep track of local carrier rules.
Rhonda Petruziello, CPC, reimbursement specialist for the Cleveland Clinic Foundation in Cleveland, says that some insurance companies recognize a certain way of billing. On the HCFA 1500 form, some carriers want you to line itemize each charge because they do not recognize quantity designators, whereas other carriers may say to group it all into one code and put the quantity amount.
Some insurance carriers have electronic billing software that is not equipped to read anything more than a five-digit CPT code, Petruziello adds. In these instances, it is necessary to submit a hard copy claim to ensure that the carrier understands what is being coded. Knowing the carrier-billing format at the beginning of the patient billing process if the carrier recognizes modifiers can save time and money for neurologists submitting claims.
Medicare carriers have different policies in different regions. In North Carolina on any new patient (99201-99205) visit, Medicare does not want to see the -25 modifier (significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service) on an evaluation and management (E/M) when a procedure is performed, says Pat Moore, vice president of reimbursement for Healthcare Business Resources Inc. (HBR) in Durham, N.C. They expect you to bill an evaluation and management (E/M) code and a procedure, but they tell you not to use the modifier because it will bounce out on their edits for having too many -25 modifiers. But in Florida, coders have to use the -25 modifier for Medicare.
How to Create a Carrier Log
Setting up a strict coding policy that does not take these differences into account can mean lost revenue and even lost payer contracts. To keep track of different policies and ensure that their physicians get accurately reimbursed, Moore has set up a system called Coding Considerations at HBR.
Coders for neurology are urged to keep a log for every one of their clients. This log should include sections on all of the payers neurologists [...]
