Ob-Gyn Coding Alert

When a reimbursement claim has been denied, the appeals process can be frustrating. Detailed documentation is crucial to winning the appeal and getting the appropriate compensation.

Barbara J. Cobuzzi, MBA, CPC, president of Cash Flow Solutions, a medical billing and coding consulting firm in Lakewood, NJ, offered several successful appeals scenarios.

A high-risk pregnancy patient had 18 visits during the prenatal phase. A cesarean delivery was performed, and billed as 59510 (routine obstetric care including antepartum care, cesarean delivery and postpartum care). The practice also billed for six evaluation and management (E/M) visits, with various dates, depending on the documentation, using codes 99212- 99215 (office or other outpatient visit for the evaluation and management of an established patient [with various levels of history, examination and medical decision-making]). The carrier paid $1,600 for the global of 59510 and denied all the other charges.

The first steps in the appeals process, says Cobuzzi, were to get the records copied, write a simple letter explaining the complexity of the case and the reasons for the additional visits (outlined by date). We then went on to say that the standard for routine care is 12 visits, and therefore the payer was obligated to pay for the additional services. We were careful to indicate the medical necessity of the additional visits. (Please note that some payers say that 14 visits is the normal package, but I try to slant it toward the bottom of the range when trying to get paid for complex cases.)

In this situation, merely explaining the complexity of the case was enough to tip the scales in the practices favor.

In another example, a doctor was set to perform a precertified laparoscopic assisted vaginal hysterectomy (LAVH), using CPT 58550 (laparoscopy, surgical; with vaginal hysterectomy with or without removal of tube[s], with or without removal of ovary[s] [laparoscopic assisted vaginal hysterectomy])

Note: In CPT 2000, this code was renumbered from 56308.

While the doctor initially thought that this more conservative approach would be possible, upon doing the diagnostic laparoscopy, 49320, (laparoscopy, surgical, abdomen, peritoneum, and omentum; diagnostic, with or without collection of specimen[s] by brushing or washing [separate procedure]) (formerly 56300), which is bundled into 58550, the doctor determined that he could not do the procedure via scope and converted to an open total abdominal hysterectomy (TAH) using code 58150 (total abdominal hysterectomy [corpus and cervix], with or without removal of tube[s], with or without removal of ovary[s]). Instead of billing 58550, the bill was for 58150 and 49320 (not bundled). The payer only paid for the diagnostic laparoscopy (49320) since 58150 was not pre-certified.

Again, says Cobuzzi, a letter to the payer indicated the order of events, the reason the original precertified procedure could not be done and what was done in its place. We also included the operative note and all the pathology reports the office had on this patient. I also recommended to themas I would to any practicethat the doctor notify his pre-certification staff when he does a different surgery than planned. The staff should immediately call the payer and amend the approval. This particular case took a great deal of effort to get paid right.

Cobuzzi offered another appeal scenario frequent to ob/gyn practices. She says that an area that often needs appealing is the denial of both transvaginal and abdominal ultrasound (see Ob-Gyn Coding Alert, November 1999, page 83 for a related story).

If the doctor has the documentation on the medical necessity of doing both (i.e., an obese patient), says Cobuzzi, you could appeal the inappropriate re-bundling by the payer. From what I have seen, commercial payers often bundle both procedures.

Each of these examples shows where there is a reason or excuse why the proper payment was not processed by the payer, says Cobuzzi. Surprisingly, there are many times when the claim is straightforward, even precertified, and still not paid right, is denied for medical necessity, or is improperly re-bundled. Cobuzzi encourages ob/gyn practices to check that they have the documentation that supports the appeal and Go after them (the payers). They count on offices to write off what was not allowed, even if the payer made these changes inappropriately, not in accordance with CPT coding standards. This happens every day.

While the examples shown above are specific to ob/gyn claims, when it comes to the appeals process, there are several steps that are standard for any medical practice. Curtis Udell, CPAR, CPC, president of Emphysys, Inc., a physician reimbursement and consulting firm based in Cumming, GA, outlined the components necessary to mount a viable appeal:

1. Identify the problem. In most cases, says Udell, the problem with the claim is not spelled out in the reject notice, it just says improper code. When you do the follow-up, contact the payer and find out exactly what the reason for denial was. A lot of time can be wasted in fixing what the coder thought was the problem, when it may be a series of problemsa place of service issue, a modifier not used, bundling of services, etc.

2. Determine the payers requirements. Once the problem is identified, go back to the policy manual or the payer to determine the correct way to process the claim and the exact documentation that the payer requires.
According to Udell, coders have to work closely with their doctors to encourage the most thorough documentation. The medical record is the ultimate billing document. Appeals are successful, based on documentation by the physician or provider. Documentation is paramount.

3. Give them what theyre asking for and then some. Udell recommends that practices dazzle the payer with as much information/documentation as possible. There is no such thing as overkill in an appeals case.

While these three steps may seem fairly rudimentary and may be a little exhausting, they are the most likely path to a successful appeal.

Other Pointers From the Pros

Apart from the key steps outlined, Udell has some general recommendations and observations for mounting successful appeals:

Involve the patient. Practices are reluctant to involve patients in the reimbursement process, says Udell. Sometimes they erroneously feel the denial is a reflection of their abilities. The patient or the human resource person at the patients place of employment should be working with you and the insurance company to try to get payment. Remember that when working with a large group health plan, the human resources staff/department is going to be evaluating employee satisfaction from year to year to determine whether to keep their current plan. This can be advantageous for medical practices having difficulty with a particular carrier.

Submit hard copies. The increased use of electronic filing is causing some claims to be rejected. Often charts or other data are lost in transmissionthe required information doesnt make it to the payer. Sending a hard copy of the entire claim documentation is a simple step that can save a lot of headaches in the long run. As Udell says, E-claims are a big plus for basic services, but for complex claims, its still best to submit the record in its totality and in hard copy, with a detailed cover letter that explains the situation.

Know each companys policies. With ob/gyn practices in particular, where there are likely to be certain circumstances where conditions and events are outside basic servicesfor instance, if a patient is diabetic or has some other chronic problemoffice staff should be aware of what is and isnt included with each carrier. Knowing in advance what is considered over and above general care for the ob package will help you prepare for a possible appeal, says Udell. Keep current copies of all the different policy manuals together as office reference materials.

Develop an internal system. When it comes to appeals, most of the steps involved depend on one person, particularly in smaller ob/gyn practices. Whenever possible, breaking up the functions of keying in codes, accounts receivable, adjustments and appeals provides for a much more comprehensive system of checks and balances. Even in a small office where this is not possible, Udell says, there have to be set financial policies and procedures, and most small practices (five doctors or fewer) just dont have this. If you dont have a systematic claims process, you dont have an appeals process. Most practices treat every case as an individual. While this is good practice management when it comes to the medical treatment of the patient, when it comes to billing, there have to be set policies that are uniform for all patients.

Establish contacts. Establish a regular contact at every insurance company. By building a rapport with one person, you are more likely to get the inside scoop and have your appeals fast-tracked to resolution.

Follow up, follow up, follow up. There is no real trick to this, says Udell. Insurance companies know that appeals are a battle of time and will. Practice managers have to persevere and keep in contact with the insurer
about the status of the appeal.

For more help with appeals, visit your states Medicaid Web site. Several of the sites include outlines on how to appeal denials.