Ob-Gyn Coding Alert

Most ob/gyn practices have their RNs precertify their surgeriesthat is, the nurses call the insurance company with the proposed plan of treatment to verify coverage. Then, after the surgery is completed, the coders are given the surgical reports to initiate the billing process.

Our billing department doesnt handle coding for precertification. Our nurses do that, says Connie Borgialli, a billing clerk for Ob/Gyn Associates in Marquette, MI. We dont get anything until after the surgery when we get the procedure report. We code off of that.

This system works for her, says Borgialli, because billing clerks in her office dont have the time to do precertifications. Precertified surgeries are billed electronically to commercial insurers, so payment typically comes in within 2-3 weeks.

However, not all ob/gyn practices are successful with the traditional model for coding and billing surgeries. In some practices, particularly those that dont send claims electronically, it is difficult to collect payment after the surgery and, often, the accounts receivable (A/R) turnaround time is too long.

One solution to streamlining the surgical billing process is for the billing department to pre-code all of the possible surgical procedures that may be done for every surgical patient. That way, says Denise Maestas, supervisor of patient accounting at Infertility, Gynecology & Obstetrics Medical Group in San Diego, you can make sure that insurance covers all of the surgical options. In addition, patients know ahead of time what portion of the bill they will have to pay. You can begin to collect payment up front, and you can reduce your A/R days because much of the coding work is done before the surgery.

Maestas follows a very specific procedure each time that a patient needs surgery:

Before the Surgery

First, she receives the physicians progress notes from the preoperative examination, in which he or she describes the problem, the exam findings and the intended treatment. It is from this document that Maestas determines both the diagnosis codes and the CPT surgical codes.

For example, she explains, a 62-year-old woman presents in the office with occasional vaginal bleeding. The physician performs an examination, after which he recommends a hysteroscopy and an endometrial biopsy of the cervix. Maestas identifies the proposed procedure with the CPT code 56351 (hysteroscopy), and links it with the ICD-9 code for postmenopausal bleeding (627.1). Charges for the procedure are determined using coding software.

Second, Maestas contacts the patients insurance carrier, and, based on her background as a certified medical assistant, she describes the situation and the proposed surgical plan. You have to be knowledgeable of the medical terminology, Maestas says. However, she does not believe that a clinician must do surgical precertfications. Ive trained all the women in my office to do the same [...]