Orthopedic Coding Alert

Align with MAC requirements and keep clean and precise documentation.

Are you appealing for denied claims? You need to go back, check, and rectify your claims submissions. Make sure your first claims submissions are clean. Here are 10 essential tips from Novitas Solutions, a Part B contractor in 11 states. Novitas recently shared a whole wealth of information about how your practice can avoid denials and any consequent need for appeals.

1. Confirm that all data pertaining to the service is accurate. Missing just one important element — such as the correct date of service — can cause your claim to enter the denial pile. You’ll spend a matter of seconds scanning your claim for accuracy before submitting it, but that will save a lot of time down the road when you don’t have to appeal. Make sure you have all needed essential and accurate details, for example, date and place of service, NPI of the referring and billing physician, procedure code(s) and modifier(s), and more.

2. Familiarize yourself with Local Coverage Determinations (LCDs). CMS defines LCDs as “a determination by a fiscal intermediary or a carrier under part A or part B, as applicable, regarding whether or not a particular item or service is covered on an intermediary or carrier-wide basis…” This means that these are often different based on which Part B MAC you’re billing, so keep them handy to see your local rules and regulations for any particular service. “ This is in contrast to national coverage determinations in which there is a uniform policy among the intermediaries,” says Gregory Przybylski, MD, director of neurosurgery at the New Jersey Neuroscience Institute, JFK Medical Center in Edison. LCDs are proving to be a significant problem in orthopedics, as many ICD-10 codes are missing from them.

3. Get to know the National Coverage Determinations (NCDs). These directives show you CMS’s national rules on how to report a particular service. Example, for NCD of MRI procedures, refer to: https://www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/Downloads/R135NCD.pdf.

4. Use modifiers when applicable. Reporting a global code when someone else has already reported the same code with a TC (Technical component) modifier will prompt a denial for you. In these cases, when a modifier such as 26 (Professional component) applies, your appropriate use of it will make or break your claim.  “This issue typically applies to imaging services in which the provider performing the professional interpretation does not own the equipment used that created the image,” Przybylski says.

5. Ensure that your documentation of a repeat or duplicate service shows the distinct nature of the two services. If you don’t document them separately — and use the appropriate modifier such as 76 (Repeat procedure or service by same physician or other qualified health care professional) — you’ll be facing denials.

6. Send supporting documentation when you’re using modifiers that require more detail, such as modifier 52. Some LCDs or NCDs will specifically indicate that you must submit additional records if you’re appending modifier 52 (Reduced services) or 22 (Increased procedural services). In these situations, if you submit the code and modifier but fail to send in the documentation, your service will be denied. Confirm with your provider when you can actually append these modifiers. “Modifiers that report an alteration from the typical service provided are naturally subject to increased scrutiny, and therefore pre-emptively providing supporting documentation is key to avoiding a denial,” Przybylski says.

7. If the MAC requests documentation, send it immediately. Typically, when MACs ask for more information, they won’t pay you until you send it and they review it. Comply with any record requests to make certain you don’t slow down reimbursement.

8. Ensure that documentation includes the rendering physician’s signature. There’s nothing as disheartening as sending in a claim, followed by supporting documentation, but failing to have the doctor sign the note and seeing a denial after all that work.

9. Describe unlisted procedure codes. Just turning in an unlisted CPT^® code is not enough to collect payment from your MAC. You should submit your claim electronically with a short description of the procedure in the electronic equivalent of box 19 of the CMS-1500 form. Follow up with the paper claim and documentation and include a note stating that you’re sending a “documentation” copy, not a duplicate copy. “Remember that unlisted codes represent work performed for which there is no existing CPT^® descriptor reflecting the service,” Przybylski says. “Reporting unlisted procedures (such as minimally-invasive approaches to the skull base) will naturally require review of an operative note to document the nature of the procedure.  It may also be helpful to provide an example of a procedure with CPT^® descriptor that is analogous or substantially similar to the one provided to assist the carrier in determining the equivalent work value for the unlisted procedure.”

10. For Medicare Secondary Payer (MSP) claims, always include information from the primary insurer. MSP needs to know how much (if any) the primary payer already reimbursed you before processing the claim.

Resource: To read Novitas’ complete list of ways to avoid appeals, visit www.novitas-solutions.com and click “Appeals.”