Set Up Internal Log to Track Payer-specific Coding Policies
Published on Thu Jun 01, 2000
Many neurosurgeons 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, neurosurgeons and neurosurgical 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. While most plans pay for spine surgeries such as a laminectomy (63047) or removal of a herniated disk (63030) no matter how many levels are addressed, some payers enforce limitations that restrict payment to two levels only.
Rhonda Petruziello, CPC, reimbursement specialist for neurosurgery at Cleveland Clinic Foundation in Cleveland, says that some insurance companies recognize a certain way of billing. Petruziello says, Some carriers want you to line itemize each charge because they dont recognize quantity designators, whereas if youre billing for the same code at different levels, 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 at the beginning of the billing process if the carrier recognizes modifiers can save time and money for neurosurgeons submitting claims.
Medicare carriers have different policies in different regions. In North Carolina, on any new patient (99201-99205) visit, Medicare doesnt 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 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, we have to use the -25 modifier for Medicare.
Setting up a strict coding policy that doesnt 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 neurosurgery are urged to keep a log for every one of their clients, with sections on all of the payers they contract with, listing whether they pay for unlimited levels in spine surgeries or if there are restrictions, whether codes should be line itemized, if modifiers are recognized, etc.
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